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Short fiber-reinforced composite restorations: A review of the current

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DOI: 10.1111/jicd.12330

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Received: 26 December 2017    Accepted: 3 January 2018

DOI: 10.1111/jicd.12330

REVIEW ARTICLE
Dental Biomaterials

Short fiber-­reinforced composite restorations: A review of the

current literature

Sufyan Garoushi1  | Ausama Gargoum2 | Pekka K. Vallittu1,3 | Lippo Lassila1

1
Department of Biomaterials Science and
Turku Clinical Biomaterial Center, University
of Turku, Turku, Finland
2
Department of Restorative
Dentistry, Libyan International Medical
University, Benghazi, Libya
3
City of Turku Welfare Division, Oral Health
Care, Turku, Finland
Correspondence
Dr Sufyan Garoushi, Department of
Biomaterials Science, University of Turku,
Turku, Finland.
Email: sufgar@utu.fi
Abstract
A newly-­recommended method for restoring large cavities is the biomimetic ap-
proach of using short fiber-­reinforced composite (SFRC) as dentine-­replacing mate-
rial. The aim of the current review was to present an overview of SFRC and to give
the clinician a detailed understanding of this new material and treatment strategy
based on available-­literature review. A thorough literature search was done up to
December 2017. The range of relevant publications was surveyed using PubMed and
Google Scholar. From the search results, articles related to our search terms were
only considered. The search terms used were “short fiber-­reinforced composite”,
“everX posterior”, and “fiber-­reinforced composite restorations”. Of the assessed ar-
ticles selected (N = 70), most were laboratory-­based research with various test speci-
men designs prepared according to the ISO standard or with extracted teeth; only
four articles were clinical reports. A common finding was that by combining the SFRC
as a bulk base with conventional composite, the load-­bearing capacity and failure
mode of the material combination were improved, as compared to plain conventional
composite restoration. In the reviewed studies, the biomimetic restoration technique
of using SFRC showed promising characteristics, and therefore, might be recom-
mended as an alternative treatment option for large cavities.

KEYWORDS
biomimetic composite restoration, everX Posterior, fracture toughness, large cavities, short
fiber-reinforced composite

1 |  I NTRO D U C TI O N A typical biomimetic restorative approach is the combined use

According to the principles of modern restorative dentistry, the
restoration and the tooth should form a structurally-­adhesive and
mechanically-­combined form, which has the ability to withstand re-
petitive forces over a prolonged period of time. The definition of the
term “biomimetic” in the field of restorative dentistry is the study
of the structure and function of the tooth tissue as a model for the
design and manufacturing of materials, and techniques to restore or
replace teeth.1 In fact, the primary aims of biomimetic dentistry are
to be as minimally invasive as possible, and to substitute the missing
hard dental tissues with restorative materials closely resembling the
natural tissues regarding their mechanical features and properties.1
of materials to replace the different tissues, such as the use of por-
celain to replace enamel and composite resins to replace dentine,
combined with optimized bonding strategies. According to what has
been said thus far, one could say that an ideal restoration would be a
bonded porcelain restoration substituting the missing enamel layer,
and if dentine also needs to be replaced, composite resin should
be used under the porcelain coverage. As logical as it might sound,
however, the use of this approach is limited in practice, due to both
financial and technical limitations.1
With their improved mechanical properties and wear resistance,
and given their more favorable cost, resin composites have, for many,
become the material of choice not only for dentine replacement but

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https://doi.org/10.1111/jicd.12330
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also for the restoration of the whole posterior tooth in the posterior
region. 2 Clinically, it is widely recommended that an incremental lay-
ering technique be used in order to reduce the resin polymerization
stress and to develop better mechanical properties. 2
To locate the ideal composite material for the restoration of large
class I and II cavities in posterior teeth has long been a vital issue in
restorative dentistry. 2 To be able to construct a perfect composite
restoration, one must be aware of the potential risk factors and char-
acteristic types of failure in the posterior region. Two main causes of
posterior restoration failure have been identified: bulk fracture and
secondary caries. A review article by Brunthaler et al. demonstrated
that early failure was more closely related to fractures, while car-
ies was more likely to be the background of long-­term failure.3 Da
Rosa et al. and Pallesen and Qvist also demonstrated in their long-­ F I G U R E   1   Schematic representation of biomimetic (bilayered)
term studies (with more than 10 years of follow up) that failure was posterior composite restoration: lost dentine is replaced by tough
short fiber-­reinforced composite (SFRC) and covered by surface
more frequently the result of fracture than of caries.4,5 This finding
layer of (particulate filler composite [PFC]) resin
suggests that bulk fracture is a considerable risk to posterior resto-
rations, regardless of the lifespan or the age of these restorations.
Throughout its well-­documented history in industry application, The question arises whether this new SFRC material is able to re-
fiber-­reinforced composite (FRC) technology is constantly evolving inforce the dental structure and lead to improve fracture resistance
as a result of innovative treatment solutions. Utilizing different types and more favorable fracture patterns when applied according to bio-
of fibers with various orientations and lengths is quite an old idea mimetic principles.
in engineering and in architectural applications to construct devices Thus, the sole purpose of the present study was to exclusively
with high strength and fracture toughness. review the available literature on the biomimetic restorative tech-
The use of FRC in dental applications has been discussed in the nique by using SFRC material, and to give clinicians a comparative
6 overview of this method with traditional composite techniques in
literature since the early 1960s. Today, fiber reinforcement has be-
come an effective material of choice within restorative dentistry. In terms of their biomechanical stability.
2013, short fiber-­reinforced composite (SFRC) (everX Posterior; GC,
Tokyo, Japan) was introduced to the market with the goal to mimic the
2 | M ATE R I A L S A N D M E TH O DS
stress absorbing properties of dentine. The SFRC material is intended
to be used as bulk base in high stress-­bearing areas for restoring vital
2.1 | Eligibility criteria
and non-­vital teeth (Figure 1).1 It consists of a combination of a resin
­matrix, randomly-­orientated E-­glass fibers, and inorganic particulate Articles eligible for inclusion in the present review were published
fillers. The resin matrix contains bisphenol-A-diglycidyl-dimethacrylate in the English language, peer reviewed, and dated from 2006 to
(bis-GMA), triethylene glycol dimethacrylate, and polymethylmethac- 2017. The articles selected had to include the search terms either
rylate, forming a matrix called semi-­interpenetrating polymer network in the title or abstract. Published articles that were full text were
(semi-­IPN), which provides enhanced bonding properties for repairs preferred. Articles that were unpublished, personal communica-
1 tions, background information, and advertisements were filtered
and improves the toughness of the polymer matrix.
The rationale behind the usage of fiber reinforcement is partly and excluded.
to internally strengthen the structurally-­
compromised tooth and
partly to prevent the occurrence of fractures. The efficacy of fiber
2.2 | Data sources
reinforcement is dependent on several factors, including the resins
used, the length of the fibers, the orientation of fibers, the position A literature electronic search was performed through PubMed and
of the fibers, the adhesion of the fibers to the polymer matrix, and Google Scholar by crossing the key words: “short fiber-­reinforced
the impregnation of the fibers into the resin.6 The reinforcing effect composite”, “everx posterior”, and “fiber reinforced composite res-
of the fiber fillers is based on stress transfer from the polymer matrix toration”. During the review process, the relevant literature was
to the fibers. However, the individual fibers also act as crack stop- further obtained through the reference sections of the retrieved ar-
pers. Stress transfer from the polymer matrix to the fibers is essen- ticles to provide more supportive information.
tial. This is only possible if the fibers have a length equal or greater
than the critical fiber length. The critical fiber lengths of E-­glass with
2.3 | Search strategy
bis-­GMA polymer matrix vary between .5 and 1.6 mm.6 Also, the
position and orientation of the reinforcement within a structure is After omitting the duplicates/repetitive articles, a total of 70 full-­
known to influence its mechanical properties.6 text articles were studied and concluded for review (Figure 2). Two
GAROUSHI et al.
Identification
Initial electronic search
Screening
Full-text articles assessed
for eligibility (n = 68)
Elegibility
Full-text articles (n = 65)
Included
F I G U R E   2   Flow diagram (PRISMA
format) of the screening and selection
process
investigators independently searched and screened the results
using the agreed inclusion criteria: (a) laboratory or clinical study;
(b) related to SFRC material; (c) direct comparison between short
fiber-­reinforced and -­unreinforced composite restorations; (d) direct
comparison between properties of SFRC and conventional particu-
late filler composite (PFC) resins; (e) published in a peer-­reviewed
journal; (f) reported manufacturer information; and (g) published in
English.
Whenever it was not possible to make this determination, the
full-­text article was examined. Subsequently, all relevant articles
were obtained, and those not meeting the inclusion criteria were ex-
cluded from the review.
3 | R E S U LT S A N D D I S CU S S I O N
The purpose of this broadly-­inclusive review was to provide clini-
cians with general knowledge of the biomimetic restoration tech-
nique by using SFRC, and providing clinical related evidence of why
it should be a recommended treatment option for deep and large
class I and II cavities. In order to understand the smart biomimetic
technique, a discussion of SFRC physical properties correlating to
|
      3 of 9
(n = 345 titles)
Records excluded
after title and
abstract screen
(n = 277)
Full-text articles
excluded with
reason (n = 3)
Additional articles
(n = 5) identified through
other sources (cross
references)
Final number of studies
included (n = 70)
their performance needs to be addressed. After a detailed and thor-
ough study of the reviewed articles, tested characteristics were di-
vided into five main headlines; each headline contained one or more
properties to be addressed.
3.1 | Mechanical properties and structural
characterization of short fiber-­reinforced composites
Many studies have looked for ways to improve the mechanical prop-
erties of PFC resins. These include choosing a suitable resin matrix,
using different curing methods, and improving the filler content. 2
Nonetheless, these resins do not have the adequate strength and
toughness to replace the lost tooth structure.1,2 SFRC has already
shown an improvement in mechanical properties when used in
vivo.7,8 The fracture-­related material properties, such as fracture
resistance, deformation under occlusal load, and the marginal deg-
radation of materials have usually been evaluated by the determi-
nation of the basic material parameters of fracture toughness and
flexural strength and modulus.9 Garoushi et al. determined the
physical properties of SFRC in comparison to different commercial
PFC,8 and stated that SFRC differed significantly in its physical prop-
erties and has superior fracture toughness (2.9 MPa m1/2), flexural
 |
4 of 9       GAROUSHI et al.
strength (124 MPa), and modulus (9.5 GPa) compared to other tested
bulk-­fill or conventional PFC materials. It is important to note that all
the properties of fiber composites are strongly dependent on micro-
structural parameters, such as fiber diameter, fiber length, fiber ori-
entation, and fiber loading.6 Bijelic-­Donova et al. evaluated several
fiber-­and matrix-­related characteristics of SFRC in comparison to
conventional PFC resins.10 In addition, they investigated the correla-
tion between the mechanical tests and compressive fatigue limits
of the composite resin materials tested.11 The results showed that
1/2
SFRC had a statistically higher fracture toughness (2.4 MPa m
and fatigue limit than conventional PFC resins (range: .9-­1.1 MPa
1/2
m ). They showed a strong correlation between fracture tough-
ness and fatigue performance, and the SFRC was able to sustain
both compressive static and fatigue load.10,11 The authors declared
that the toughening capability of SFRC over their competition is at-
tributed to two main factors: the millimeter-­scale short fiber and
semi-­IPN structure. Therefore, they recommended SFRC in high
stress-­bearing areas for its enhanced toughness. Moreover, Goracci
et al. reported that SFRC had significantly higher flexural strength
(201 MPa) in comparison to several tested bulk-­fill and conventional
PFC resins.12
In further corresponding studies, Tsujimoto et al. determined the
relationship between mechanical properties and bond durability of
SFRC.13 They showed that shear fatigue strength of the adhesive
system with SFRC was significantly higher than that of PFC com-
posite resins tested. They also highlighted that the enhanced frac-
ture toughness (2.8 MPa m1/2) and bond durability of SFRC with
universal adhesive suggest that SFRC might perform better in high
stress-­bearing restorative situations relative to composite resin with
a conventional type of filler.
A number of manufacturers have developed short fiber com-
posite resins, which claimed to be a solution for conventional PFC
resin weakness. Recently, Garoushi et al. evaluated and compared
certain important mechanical properties of these commercial short
fiber composite resins (Alert, EasyCore, Build-­It, TI-­Core, and everX
Posterior) in relation to their microstructural characteristics.14 In
agreement with previous studies, SFRC (everX Posterior) showed rel-
1/2
atively high fracture toughness (2.4 MPa m ) than all other tested
1/2
materials (range: 1.3-­1.8 MPa m ). Garoushi et al. stated that other
commercial short fiber composite fiber lengths measured using the
micrometer scale (20-­60 μm) are well below the critical fiber length.
Of course, the focus should be paid to the aspect ratio of the fiber
fillers rather than their length only, which was not considered in the
study. However, the fiber length explained the difference in fracture
toughness values between the everX Posterior and other microfi-
ber reinforced composite resins. Moreover, as shown in Garoushi
et al.’s previous study millimeter-­scale short fiber fillers could stop
the crack propagation and provided increase in the fracture resis-
tance of SFRC.7 They reported that differences in fiber aspect ratio,
critical fiber length, fiber loading, fiber orientation, and adhesion be-
tween the fiber and matrix are the main factors that could improve
or impair the mechanical properties of fiber-­
reinforced compos-
ites.14 Abdul-­Monem et al. studied the effect of water aging (up to
6 months) on the flexural strength and fracture toughness of SFRC
and other conventional PFC resins.15 Although aging in water de-
creased the mechanical properties of SFRC, it remains much higher
than the other tested PFC resins.
Surface microhardness of composite resin materials correlates
with their mechanical properties, such as abrasion resistance and
form stability. Additionally, microhardness is considered a strong
indication to the degree of conversion of the material. Accordingly,
measuring the surface microhardness could be a method of deter-
) mining the longevity and the service life of the direct resin-­based
restorations.16 Al Sunbul et al. investigated the surface micro-
hardness of SFRC and several bulk-­fill and conventional PFC res-
ins.16 After 24 hours of curing among other tested materials, SFRC
yielded the highest Vickers hardness (61.4) at baseline measure-
ments. In addition to the previous mentioned papers, many other
laboratory studies have demonstrated the improved mechanical
performance of SFRC, especially fracture toughness and flexural
strength in comparison to the tested bulk-­f ill or conventional PFC
resins.17–22
However, Fronza et al. reported that the mechanical perfor-
mance of SFRC was intermediate and was not expected compared
with that of other PFC materials. 23 In fact, in their study, they used
thin specimens (.5 mm) to test the biaxial flexural strength, and it is
likely that the fibers were aligned perpendicular to the applied load,
which significantly reduced their reinforcement capability.
3.2 | Polymerization shrinkage and microleakage of
short fiber-­reinforced composites
Polymerization shrinkage is one of the most critical limitation of
light cured dental composites. 2 Such shrinkage induces contraction
stress at the interface between the composite resin and cavity walls,
leading to gap formation and secondary caries. 2 Many studies have
reported efforts to develop methods to eliminate this problem. One
of these recommended methods is using the incremental technique
to reduce polymerization shrinkage; however, it is time consuming,
increases the risk of contamination, and could create voids between
layers. 2 Bulk-­fill material has been introduced to accelerate the ap-
plication and reduce chairside time and polymerization shrinkage.8
Previously studies have reported short, randomly-­
oriented,
fiber-­
reinforced composite (FRC) low polymerization shrinkage
compared to PFC resins. 24 Garoushi et al. compared the polymer-
ization shrinkage of various commercial posterior composite resins,
including bulk-­fill and SFRC resins using the strain gage method.8
They concluded that SFRC had the lowest shrinkage strain (.17%),
and attributed this to the short fiber fillers and plasticization of the
polymer matrix. They clarified that anisotropic materials properties
vary according to the orientation of reinforcing fibers, and shrinkage
is not equal to all directions and the polymerization shrinkage is con-
trolled in the direction of the fibres.8 Therefore, during polymeriza-
tion, the material is not able to shrink along the length of the fibers.
It retains its original dimensions horizontally, but the polymer matrix
between the fibers can shrink.
GAROUSHI et al.
In another study, Garoushi et al. evaluated the magnitude of
SFRC resin on polymerization shrinkage strain, shrinkage stress, and
marginal microleakage of the restoration. 25 They claimed that the
presence of short fibers in the composite resin increases resistance
to microcracking, while significantly decreasing shrinkage stress
and microleakage compared to those restorations made from PFC
resins. 25 This is in agreement with Tsujimoto et al., who reported
that SFRC had significantly lower volumetric shrinkage (1.15%) than
the other tested bulk-­fill and conventional PFC resins (range: 1.3-­
21
2.4%). Confirming the previously-­
mentioned studies, Bocalon
et al. concluded that the replacement of a small fraction of filler par-
ticles with glass fiber fillers significantly reduced post-­gel shrinkage
in the range of 30-­72%. 26 In contrast, in another study, Bocalon et al.
showed that replacement of a small fraction of filler particles with
glass fiber fillers significantly increase shrinkage stress. 27
Miletic et al. reported that volumetric shrinkage of SFRC was
similar or lower than tested conventional PFC resins, and that glass
fiber fillers did not alter the shrinkage behavior of SFRC in the mea-
suring setup used. 28 This in accordance with Al Sunbul et al., who
investigated the shrinkage stress of 18 commercially-­available com-
posite resins. 29 They reported that polymerization shrinkage stress
values ranged from 3.94 to 10.45 MPa, and SFRC had a value of
5.16 MPa, which was similar or lower than many of the bulk-­fill and
conventional PFC resins tested.
Interestingly, Shouha and Ellakwa reported that the addition of
5 wt% of short fiber fillers to resin matrix did not effect polymer-
ization shrinkage stress values, whereas 10 and 20 wt% loading re-
sulted in higher stress values.30 According to Shouha and Ellakwa,
an increase in shrinkage stress from the fiber load of >5 wt% could
arise predominantly from increases in modulus and stiffness of the
material. This in line with Fronza et al., who reported higher shrink-
age stress value for SFRC (4.3 MPa) in comparison with four other
bulk-­fill and conventional PFC resins (range: 2.6-­3.7 MPa).31
Microleakage studies for many scientists are still the method
employed to obtain a preliminary idea about the quality of a new
material or combination of materials. 2 The use of SFRC as a sub-
structure for biomimetic composite restorations in large class I and
II posterior teeth has shown a trend toward less leakage compared
to conventional composites. 25,32–35 Boutsiouki et al. evaluated the
microleakage of class I cavities restored by different composite
32
base materials under directly-­p laced PFC resin. Data showed
that teeth restored with an SFRC base had the lowest microleak-
age values in comparison with other tested materials. Boutsiouki
et al. stated that SFRC exhibits beneficial effects in shrinkage
stress absorption, which is reflected in low microleakage values.
Garoushi et al.’s findings were similar; SFRC base material using
the biomimetic technique (class II restorations) showed statisti-
cally lower microleakage values compared to other restorations
33
made of different bulk-­f ill base materials. Patel et al. also studied
microleakage in deep class II cavities restored by different bulk-­
fill and conventional PFC resins, and found that SFRC showed the
least microleakage values, while conventional PFC resin showed
the highest. 34 Furthermore, Patnana et al. concluded that SFRC
|
      5 of 9
restorations in class V cavities showed an improved marginal
integrity when compared to the conventional PFC resin resto-
rations. 35 However, some other authors reported no certain effect
of SFRC on microleakage and marginal adaptation of composite
resin restorations. 36–38
Despite studies showing differences, in some cases, yielding
poorer in vitro marginal quality, in polymerization shrinkage stress
attributed to different measuring techniques, it is unlikely that a
strong relationship between in vitro marginal analysis and clinical
performance can be determined. Furthermore, through searching
the literature, one is faced with the difficult task of comparing often
contradictory data originating from different devices and specimen
configurations. Such discrepancies in literature are explained by the
fact that shrinkage stress is a local physical state, and therefore, the
stress magnitude developed by a specific material is largely affected
by specimen geometry and boundary conditions. However, in their
studies, Heintz et al. and Ferracane and Condon and showed that the
marginal breakdown or degradation of composite resin restoration
has excellent correlation with fracture toughness of the material.9,39
3.3 | Depth of cure and light transmission of short
fiber-­reinforced composites
Several manufacturers claim that bulk-­fill composite resins can be
applied to a depth of 4-­5 mm with enhanced light curing. In some
clinical situations, the light guide tip cannot be placed in close con-
tact with the restoration surface. Therefore, any increase in the
depth of cure obtained by curing should be considered important
for daily clinical practice. It has been documented that the degree of
monomer conversion of resin-­based composites influences their me-
chanical properties, and thus the clinical performance. 2 Therefore,
it is a fundamental requirement for the success of the composite to
have proper light curing throughout the composite layer.
Miletic et al. correlated the degree of conversion (DC) and the
Vickers hardness (VH) and translucency parameter (TP) with the
depth of cure of SFRC and different commercial bulk-­fill resins.40
They reported that SFRC had a significantly higher TP than other
tested bulk-­fill materials, and correspondingly achieved a depth of
cure of 5.09 mm. This was similar to the depth of cure measured
for SFRC by Goracci et al.12 Although SFRC is not flowable and has
more filler content than flowable bulk-­fill materials, after 20 seconds
of curing 4-­mm specimens, SFRC showed bottom-­to-­top hardness
ratios above 80%, which is clinically recommended.40 Miletic et al.
attributed this performance to the millimeter-­
scale fibers which
conduct and scatter the light better than particulate fillers.40 This
is in accordance with Garoushi et al., who determined the depth of
cure of SFRC in comparison to different commercial bulk-­fill and
conventional composite resins.8 The depth of cure of the SFRC eval-
uated in their study was similar to other tested bulk -­fill materials,
and was twice as high (4.6 mm) as other reinforced fiber composites
(Alert, 2.3 mm; Jeneric/Pentron, Wallingford, CT, USA). This was ex-
plained by the difference in filler loading and contents between the
two materials. It has been demonstrated that refraction indices and
 |
6 of 9       GAROUSHI et al.
extinction coefficients change during the polymerization of meth-
acrylate monomer systems of FRC, which enhance light-­induced
polymerization.41
In another study, Garoushi et al. investigated the influence of the
thickness of composite resin increments on light transmission, de-
gree of monomer conversion, and surface microhardness of SFRC in
42
comparison to bulk-­fill and conventional PFC resins. They showed
that the light transmission of SFRC was higher than conventional
composite at all recorded thickness levels. They concluded that
SFRC, like other tested bulk-­fill materials, provided acceptable val-
ues of DC and VH at 4-­mm thickness compared to conventional PFC
resins. The finding of their study was in agreement with other stud-
ies in the literature. 21,23,43–46
Omran et al. found similar results with regard to SFRC having
the highest mean irradiance values for both 2 and 4-­mm thick incre-
ments.47 They attributed these findings to the fundamental differ-
ence of filler content and randomly-­distributed glass fibers, which
act as a refractory index scattering light to deeper areas. They con-
cluded that SFRC can be applied safely as a substructure of 4-­mm in-
crements, which is the same as other bulk-­fill materials. Furthermore,
Li et al. showed that SFRC had significantly higher curing efficiency
48
than the full-­depth or high-­viscous bulk-­fill materials. Their results
also validating the respective manufacturer’s recommendations of
SFRC and other tested bulk-­fill composites to be cured up to at least
a 4-­mm depth.
Interestingly, Shouha and Ellakwa reported that SFRC exhibited
the deepest cure (6.7 mm) in comparison with different composite
resins.30 This was explained by the effect of relatively well-­aligned
millimeter-­scale fibers down the narrow mold enhancing light pen-
etration, as well as the greater transiency observed in SFRC mate-
rials.30 In contrast to the previously-­mentioned studies, Yap et al.
reported that none of the tested bulk-­fill composites, nor SFRC,
demonstrated a 4-­mm depth of cure for both the ISO and harness
49
test techniques. They attributed this to the differences in the type
of hardness-­testing methods; force load; dwell time of the hardness
indenter; and hardness testing protocols, including specimen design,
preparation, and storage conditions, as well as specimen mold color.
3.4 | Bonding performance of short
fiber-­reinforced composites
There is little evidence comparing the bond durability of SFRC to
dentine with that of other composite resins. Interestingly, Tsujimoto
et al. determined that the relationship between mechanical proper-
ties and dentine bond durability of SFRC using universal adhesive
13
showed improvements compared to conventional PFC resins.
Regardless of adhesive type and etching modes, the ratios of shear
fatigue strength and shear bond strength of SFRC were higher than
those of conventional PFC resins. Tsujimoto et al. clarified that the
superior mechanical properties of SFRC, especially fracture tough-
ness, could improve its bond durability with universal adhesives.
They debated that short fibers might have a reinforcing effect on the
oxygen-­inhibited layer of the adhesive and they emphasized that,
with enhanced mechanical properties and bond durability, SFRC
might perform better in high stress-­bearing situations. In another
study, Tsujimoto et al. also investigated the shear bond strength and
surface free energy of SFRC using different adhesives in comparison
with other PFC resins. They found that the bonding performance of
SFRC was the same as that for the tested PFC resins.50 This finding
was in agreement with other studies in the literature.38,51–53
Bijelic-­Donova et al. looked at the thickness effects of the oxy-
gen inhibition layer of SFRC in comparison to conventional PFC res-
ins, and evaluated the interlayer shear bond strength for all tested
resins.54 They found the thickness of the oxygen inhibition layer of
SFRC to be the highest overall, regardless of type of surface treat-
ment. They attributed the reinforcement of fibers and their orienta-
tion, which could influence the oxygen inhibition depth by favoring
the passage of oxygen. The presence of the oxygen inhibition layer
improved the interlayer shear bond strength to adjacent composite
layers, which led to more durable adhesion. As previously discussed,
Omran et al. evaluated the influence of increment thickness on den-
tine bond strength. SFRC displayed the highest mean bond strength
values in both 2 and 4 mm-­thick layers.47 They speculated that this
was correlated to the presence of micromechanical interlocking be-
tween protruding short fibers of the SFRC and dentine, which could
influence the bond strength values.
3.5 | Performance of short fiber-­reinforced
composite-­based biomimetic composite restorations
Efforts have been made to reinforce composite restorations of vital
and non-­vital teeth by using FRC as a substructure with different
orientations in order to enhance composite strength and tough-
ness.55–60 This bilayered or biomimetic composite structure is a
restoration that includes both FRC and PFC resins. Several stud-
ies have shown that the FRC substructure supports the composite
restoration and serves as a crack-­prevention layer.55–60 The FRC
substructure’s thickness has prior importance, as it influences the
failure mode and the crack-­arresting mechanism. Furthermore, the
type of FRC substructure and the thickness of the veneering com-
posite also play a significant role.57,61 In order to simplify the clini-
cal technique of using FRC inside cavities, SFRC was introduced as
a dentine-­replacing material (bulk base) to support the remaining
tooth structure and improve the durability of the final biomimetic
composite restoration.
Garlapati et al. studied the in vitro fracture resistance of
endodontically-­
treated teeth (ETT) restored with different core
materials, and concluded that among the materials tested, teeth
restored with the SFRC composite base showed superior fracture
resistance and a favorable failure mode.62 Gürel et al. evaluated the
fracture strength of endodontically-­treated premolars reinforced by
the bulk base of SFRC.63 Biomimetic SFRC-­based composite resto-
rations showed higher fracture resistance and more restorable frac-
ture type than other tested restorations. In addition, they stated that
traditional way of using fiber post is a multistep application, which
is more complex and sensitive technique in comparison with using
GAROUSHI et al.
SFRC as post-­core foundation. Gürel et al. highlighted that this bio-
mimetic restorative approach of using SFRC material is promising for
63
the posterior region. This in line with Forster et al., who studied
different designs of restoring endodontically-­treated premolars, and
found that the application of direct-­layered SFRC as post and core
in endodontically-­
treated premolars performed statistically simi-
larly in the studied conditions as natural teeth and higher than all
other tested restoration designs.64 They also emphasized that the
direct-­layered SFRC-­based biomimetic composite restoration is a
64
promising alternative technique in restoring ETT. Garoushi et al.
measured the static load-­bearing capacity of direct composite onlay
restorations made of biomimetic technique compared to bulk-­fill and
conventional PFC restorations. SFRC-­
based restorations had the
highest load-­bearing capacity compared to other direct composite
33,65
restorations.
Interestingly, Ozsevik et al. found that placing SFRC as core ma-
terial under conventional PFC composite restorations of ETT (mo-
lars) provided strength that was very similar to that of intact teeth
and superior to that of the PFC composite alone and the polyeth-
ylene FRC-­reinforced groups.66 In the discussion, they stated that,
although molar teeth were included in the study, other types of
teeth with smaller dimensions might not be suitable and could be
difficult for long fibers with FRC placement. However, using SFRC
for these teeth is easier.66 In contrast, Tekçe et al. reported no dif-
ference in the fracture resistance of class II composite restorations
reinforced either by an SFRC or polyethylene FRC base.67
In another congruous study, Eapen et al. discussed the perfor-
mance of SFRC-­based biomimetic restorations, and concluded that
SFRC can be used as a direct core build-­up material that can effec-
tively resist heavy occlusal forces against fracture and could rein-
force the remaining tooth structure in ETT.68
In addition to the above-­mentioned studies, Kemaloglu et al.,
Yasa et al., Vahid et al., and Fráter et al. also evaluated SFRC as bulk
69–72
base for large mesial-occlusal-distal (MOD) cavities in ETT.
They concluded that the restoration of severely weakened teeth
with the use of SFRC combined with conventional composites might
have advantages over conventional composites alone. They claimed
that this could be an alternative technique to prevent cuspal frac-
ture on ETT with MOD cavities. It was observed also from the sta-
tistical data that the application of SFRC with an oblique layering
technique yielded better fracture thresholds and more favorable
fracture patterns than any other studied material/technique com-
bination.72 Bijelic-­Donova et al. and Nagata et al. showed that frac-
ture resistance of oblique-­loaded anterior single crown restorations
using SFRC yielded better static and fatigue resistance than con-
ventional PFC restorations. They emphasized that SFRC should be
used in high stress-­bearing areas to yield enhanced toughness and
make biomimetic restorations more resistant to fracture and crack
propagation.11,73
Confirming the previously-­mentioned laboratory data, many au-
thors have demonstrated in their clinical reports that using SFRC as
a bulk base or core under direct composite restorations for posterior
|
      7 of 9
teeth can be considered an economical and practical measure that
could obviate the use of extensive prosthetic treatment.74–77
In contrast to the previously-­m entioned studies, Atalay et al.,
Rocca et al., and Barreto et al. reported that the incorporation
of SFRC inside the cavity of posterior destroyed teeth restored
with thick PFC resin overlays is not useful to increase their load-­
bearing capacity or to yield a better failure mode after load to
fracture.78–80 They explained that the discrepancy between their
studies and previous studies stemmed from a difference in the
thickness of overlay PFC composites, loading set-­up, and the ad-
hesive system used.
4 | CO N C LU S I O N
Based on the reviewed studies in the present review, SFRC materi-
als exhibits unique fiber and polymer variety in their composition,
and consequently, a variety of enhanced mechanical and physical
properties. The biomimetic restorative technique, using SFRC as a
substructure with PFC overlying it, is a recommended direct restora-
tion alternative, and can be used reliably for the coronal restorations
of teeth with large cavities in high stress-­bearing areas. However, we
should emphasize the correct use of the material in order to achieve
reinforcement benefits and durability.
C O N FL I C T O F I N T E R E S T S
Pekka K. Vallittu is a consultant with Stick Tech. The other authors
declare no conflicts of interest.
ORCID
Sufyan Garoushi  http://orcid.org/0000-0001-9457-2314
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How to cite this article: Garoushi S, Gargoum A, Vallittu PK,
Lassila L. Short fiber-­reinforced composite restorations: A
review of the current literature. J Invest Clin Dent.
2018;e12330. https://doi.org/10.1111/jicd.12330