Basic ResearchTechnology

Fracture Strength of Endodontically Treated Maxillary

Premolars Supported by a Horizontal Glass Fiber Post:
An In Vitro Study
Wassim Karzoun, DDS, MSc,* Amid Abdulkarim, MSc, PhD,* Abdulaziz Samran, MSc, DMD,
and Matthias Kern, DMD, PhD
Abstract
Introduction: The purpose of this study was to evaluate
the effect of a horizontal glass fiber post on the fracture
strength of endodontically treated maxillary premolars
with mesioocclusaldistal (MOD) cavities. Methods:
Sixty extracted intact upper premolars were collected,
treated endodontically (except for the control group),
and divided into 5 test groups (n = 12) depending on
the restoration type: G1 (control group, untreated
teeth), G2 (MOD preparation without restoration), G3
(MOD preparation with resin composite restoration),
G4 (MOD preparation with resin composite restoration
and a horizontal fiber post inserted between buccal
and palatal walls), and G5 (MOD preparation with a
horizontal fiber post only). The specimens were stored
in normal saline at 37 C for 2 months. Then specimens
were quasi-statically loaded in a universal testing machine until fracture occurred. Failure loads were then
analyzed with one-way analysis of variance, followed
by multiple comparisons by using Tukey honestly significant difference test (a = .05). The mode of failure was
determined by visual inspection. Results: Mean (standard deviation) failure loads for groups ranged from
411.8 N (103.9) to 994.5 N (147.3). One-way analysis of variance showed significant differences between
fracture resistances of groups (P < .001). Tukey honestly
significant difference test showed significant differences
in fracture resistance within groups (P # .05) except
between the G1 (control group) and group G4 (P $
.05). All groups (except G4) had almost favorable
fracture mode within the cervical third of the roots.
Conclusions: Under the conditions of this in vitro
study, a horizontal glass fiber post in a MOD cavity
increased significantly the fracture resistance of the
endodontically treated upper premolars. (J Endod
2015;-:16)

Key Words
Endodontically treated premolars, fracture resistance, glass fiber post, MOD cavity,
resin cement

oot canal treatment is often necessitated by pulpal infection after hard tissue loss by
caries or after tooth preparation for crowns. Endodontically treated teeth (ETT)
have a higher risk of biomechanical failure than teeth with vital pulps (1). This is actually related to the loss of structural integrity associated with the access preparation that
results in increased cuspal deflection during function, which leads to a higher occurrence of fractures (2). Several studies revealed that the ETT are less prone to fracture
when less dental tissue is removed during treatment (3). In addition, the prognosis of
ETT is influenced by different parameters such as amount of hard tissue loss (4), presence of a minimum of 1.52.0 mm ferrule height preparation (5), and post and core
material used (6).
After root canal treatment is performed, there is often a high demand for the restoration of ETT (7). Different prosthetic techniques and materials have been reported for
the restoration of ETT (3, 8). These treatment modalities include using a post and core
(8), partial or full coverage crowns (9), and direct resin composites or amalgam fillings
(10). Several post system techniques are available for the restoration of ETT. Fiber posts
can be used because of their favorable physical properties (11). Placement of post is
indicated when coronal structure is insufficient to support a core buildup (8). Sorensen
and Martinoff (12) showed that full coverage crowns did not significantly improve the
clinical success for anterior teeth, whereas they improved success rate for premolars
and molars. The substantial loss of ETT structures during preparation might worsen
the situation when endodontic treatment is associated with mesioocclusaldistal
(MOD) cavities. From this point, adhesive restorations, with the potential to reinforce
weakened tooth structure (13), seem to have an advantage over crowns, because the
preparation of a crown might weaken the tooth as well.
A horizontal fiber reinforcement of the ETT might enhance the fracture resistance
of these teeth. Therefore, the aim of this study was to evaluate a more conservative
approach than the traditional procedures when restoring endodontically treated premolars (ETPs). The null hypothesis of the study was that the presence of a horizontal
glass fiber post would not affect the fracture resistance of ETPs.

From the *Department of Fixed Prosthodontics, Faculty of Dentistry, Aleppo, Syria; Department of Restorative Dental Sciences, Al-Farabi Colleges, Riyadh, Saudi
Arabia; Department of Fixed Prosthodontics, School of Dentistry, Ibb University, Ibb, Yemen; and Department of Prosthodontics, Propaedeutics and Dental Materials,
School of Dentistry, Christian-Albrechts University, Kiel, Germany.
Address requests for reprints to Dr Abdulaziz Samran, Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-Albrechts
University at Kiel, Arnold-Heller Strasse 16, 24105 Kiel, Germany. E-mail address: aasamran@gmail.com
0099-2399/$ - see front matter
Copyright 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.01.022

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Basic ResearchTechnology
Materials and Methods
Test Groups
Sixty recently extracted caries-free upper premolars, which were
removed for orthodontic reasons, were selected and then stored in
5% formol/saline solution at room temperature. The teeth were cleaned
with a hand scaler and stored at room temperature during the study.
Teeth with similar dimensions were assigned to 5 groups of 12 specimens. Buccopalatal and mesiodistal dimensions at the level of the cervical margin were recorded with aid of a digital caliper (Links Brand;
Harbin Metering Instrument Works, Harbin, China). Analysis of variance (ANOVA) was used to determine any significant difference among
the measurements of each group (P # .05). Endodontic access cavities
were prepared as small as possible by using a water-cooled air turbine
handpiece and round burs (Dia-Tessin; Vanetti SA, Gordevio,
Switzerland). During root canal preparation the working length was
set at 1 mm short of the apical foramen. The canals were prepared
with a rotary system (X-Smart; Dentsply Maillefer, Ballaigues,
Switzerland) according to the manufacturers guidelines. Sodium hypochlorite solution (3%) was used to irrigate the canals throughout
instrumentation. The root canals were dried with paper points (Spident;
Meta Biomed Co, Incheon, Korea). The lateral condensation technique
was used for the obturation of the prepared canals by gutta-percha
cones (Spident) to the working length and sealed with eugenol-free
resin sealer (AH Plus Sealer; Dentsply DeTrey, Constance, Germany).
Subsequently, the access cavities were sealed with temporary filling
(Coltosol; Coltene/Whaledent Inc, Altstatten, Switzerland). The teeth
were stored in distilled water at room temperature for at least 72 hours.
After that, the teeth roots were embedded into an autopolymerizing resin
(Idofast Unipol; Unidesa-Odi, Madrid, Spain) up to 2 mm apical to the
cement-enamel junction (CEJ) and oriented their long axes perpendicular to horizon by using a custom-made parallelometer. Notches were
prepared in the roots to prevent dislodgement from the embedding material. To simulate the periodontal ligament situation, the roots were
immersed into melted wax to a depth of 2 mm below the CEJ and
were then embedded in acrylic resin blocks. Each root was removed
from the resin block when the primary signs of polymerization were
noticed. The wax spacer was replaced by a silicon-based impression
material (Light body, Speedex; Coltene/Whaledent Inc) that was injected
into the acrylic resin. The tooth was then reinserted into the resin
block, and the excess impression material was removed with a surgical
blade.

The MOD cavity preparation was performed to all teeth except control group teeth. Burs were replaced after 6 preparations to ensure high
cutting efficacy. For teeth preparations, cylindrical diamond burs (Dia
Tessin) under copious air-water cooling were used in a high-speed
handpiece mounted on a custom-made parallelometer to standardize
the preparation for all specimens. The teeth were assigned randomly
to 5 groups of 12 teeth each as follows (Fig. 1): G1 (the teeth were
left intact without any cavity preparation or root canal treatment and
were used as control group), G2 (MOD preparation without restoration), G3 (MOD preparation with resin composite restoration), G4
(MOD preparation with resin composite restoration and a horizontal
fiber post inserted between buccal and palatal walls), and G5 (MOD
preparation with horizontal fiber post only).
Standard MOD cavities were prepared for all groups except G1.
MOD cavities had a width of one third of intercuspal distance for
occlusal portion preparation, and one third of total buccopalatal
dimension was used to determine the width of proximal boxes. A depth
of 1 mm above CEJ was determined for cavity preparation. After finishing the preparation, all internal edges were smoothed and rounded.
Only one operator was assigned to perform all the cavity preparations.
The perforations in the teeth of G4 and G5 (for the horizontal glass fiber
post) were made at the prominent point on the buccal and palatal surfaces at the middle space between mesial and distal. The holes were
made with rounded diamond bur (Dia Tessin) with air-water spray.
Burs were replaced after every 6 holes to ensure high cutting efficacy.
Smear layer solvent gel (EDTA; Meta Biomed Co) was applied to the surface of all MOD cavities. Then the gel was removed by air-water spray.
Glass-fiber posts (White Post DC no. 0.5; FGM Produtos Odontologicos
Ltda, Joinville-SC, Brazil) of 1.4-mm diameter were airborne-particle
abraded for 5 seconds at a distance of 30 mm with 50 mm alumina particles at 0.25 MPa (Aluminum Oxide Abrasive; Heraeus Kulzer, Hanau,
Germany) and ultrasonically cleaned in 99% isopropanol for 3 minutes.
The posts were brushed and fixed in place by using self-adhesive resin
cement (RelyX Unicem; 3M/Espe, Neuss, Germany) in accordance with
the manufacturers instructions. Extremities of post were cut near the
buccal and palatal surfaces (Fig. 2). The walls of MOD cavities were
etched by using 37% phosphoric acid (Meta Etchant; Meta Biomed
Co) for 15 seconds, rinsed with water spray, and air dried. Then
MOD cavities were bonded by using dentin bonding agent (SwissTEC;
Coltene/Whaledent AG) according to the manufacturers instructions.
Flowable composite (Opallisflow; Dentscare LTDA, Joinville-SC, Brazil)

Figure 1. Study design.

Karzoun et al.

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Basic ResearchTechnology

Figure 2. MOD cavity preparation with horizontal glass fiber post.

was first applied on root canal orifices and polymerized from proximal
and occlusal areas.
Then resin composite (FiltekZ250 XT; 3M/Espe) was applied and
polymerized following the incremental technique procedure. Then all
teeth of groups were kept in physiological saline in an incubator at
37 C for 60 days. Materials used in the restorative procedures are listed
in Table 1.

difference (HSD) test (a = .05). The confidence level was 95%. Statistical analysis was performed with SPSS 18.0 (SPSS 18.0 for Windows;
SPSS, Inc, Chicago, IL). According to the significance level (a = .05)
and the sample size (n = 12), the test of choice had adequate power
to detect statistical differences, which could be used to provide clinical
recommendations.

Loading of the Specimens

All specimens were quasi-statically loaded with a crosshead speed
of 1 mm parallel to the long axis of the tooth in a universal testing machine (Instron Corp, Canton, MA) until they were fractured (Fig. 3). A
cylindrical steel bar 6 mm in diameter and 10 mm long was used. The
bar was in non-contact mode with any points on the resin composite.
The failure load of the specimen was determined when the forceversus-time graph showed an abrupt change in load, indicating a sudden decrease in the specimens resistance to compressive loading.
Specimens were visually examined for the type and location of failure,
as well as the direction of failure.

The mean values of the fracture resistance and standard deviations

are displayed in Table 2. They ranged from 411.8 N (104) to 994.5 N
(147.3). The highest fracture resistance was recorded for G1 (control group), and the lowest one was recorded for G2 (MOD preparation
without restoration) (Fig. 4). One-way ANOVA revealed significant differences between groups (P # .05). Further analysis with the Tukey
HSD test showed that G1 (sound teeth) presented significantly higher
fracture resistance values than the other groups except G4 (MOD preparation with resin composite restoration and a horizontal fiber post).
G2 (non-restored) presented significantly lower values (P # .05)
than other groups. The fracture resistance values of G3 (MOD preparation with resin composite restoration) and G2 (MOD preparation
without restoration) did not differ statistically.
The mode of failure was determined by visual inspection of all
specimens. The type of fracture behavior and the frequency are illustrated in Figure 5. There were 2 typical root fracture modes, cervical
third fracture (favorable mode) and middle and apical thirds (catastrophic mode). Almost all groups (except G4) had a favorable fracture

Results

Statistical Analysis
Data were explored for normality by using Anderson-Darling test,
which showed that data were normally distributed. One-way ANOVA was
used to compare fracture resistance means among the 5 groups,
followed by multiple comparisons by using Tukey honestly significant

TABLE 1. Materials Used for Restorative Procedures

Material

Company

Batch number

Diamond burs (Dia-Tessin)

Vanetti SA, Gordevio, Switzerland

Posts
Self-adhesive resin cement
Resin composite
Silicon impression material

White Post DC; FGM Produtos Odontologicos Ltda, Joinville-SC, Brazil

RelyX Unicem; 3M/Espe, Neuss, Germany
Filtek Z250 XT; 3M/Espe, Neuss, Germany
tten, Switzerland
Speedex; Coltene/Whaledent AG, Altsta

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Cylinder: 1206I
Round: 1010I
251013
530167
N515291
Putty: D84891
Light: D87227

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Figure 3. Fracture strength test in universal testing machine. (A) Before fracture. (B) After fracture.

mode (Table 3). G1 and G5 presented the highest incidence of favorable

fractures, but specimens in G4 presented catastrophic fracture mode.
The mode of failure in G3 and G4 was typically an oblique or vertical
root fracture at the middle or apical third of the root, extending from
bottom of the cavity down to the buccal surface, whereas the majority
of fracture modes in the other groups were horizontal or oblique fractures extending from the dentin-core junction down to the facial or
palatal surface of cervical third.

Discussion
The present study investigated the influence of a horizontal glass
fiber post on the fracture resistance of ETPs. This technique is primarily
for teeth in which no subsequent crown is planned, and there could be
an esthetic compromise. The use of natural teeth is a reliable methodology in fracture testing and has also been attributed by many authors
(5, 8, 14). Fracture resistance of the roots is one of the most important
factors when restoring ETT that have lost a considerable amount of their
crown tissue. A custom-made parallelometer was used to standardize
the preparation for all specimens (5). The ETPs were loaded in a direction parallel to the longitudinal axis to distribute the stresses more
evenly between the residual coronal wall and the restorative material,
simulating a physiological occlusion. Glass fiber posts were selected
because of their low elastic modulus similar to dentin so they can
distribute the load forces evenly along the root (15, 16).
Furthermore, these types of post systems have the advantages of
superior esthetics, ease of retrievability, and simple application
technique, allowing the clinician to complete the procedure in the
same visit. Prefabricated fiber posts and composite resin buildup are
a viable restoring technique for ETT (5). Several studies have tried to
identify the best technique and materials to be used to increase the fracture resistance of ETT (8, 17, 18). A study by Grandini et al (19) reported that restoration of ETT with fiber posts and resin composites
is a treatment option that in the short-term conserves remaining tooth
structure. This investigation compared the fracture resistance of ETPs
with different strategies of restoration that represented the clinical situations.

The null hypothesis that the presence of a horizontal glass fiber

post would not affect the fracture resistance of crowned upper premolars had to be rejected. The horizontal glass fiber post had a significant
influence on the final fracture resistance of ETPs (P # .05). The fracture
resistance of the restored premolars ranged from 411.8 N (104) for
G2 to 994.5 N (147.2) for G1 and can be compared well with previous
in vitro studies (2022). The current results show that ETPs restored
with composite resin and a horizontal fiber post provide a mean fracture
resistance of 961.3 N, which is similar to the control group with
unrestored premolars with 994.5 N. The achieved fracture resistance
can also be compared well with that of premolars restored with root
canal posts and crowns tested in a comparable study design (5), where
mean failure loads ranged from 680 N to 1085 N (depending on the
ferrule height and the number of remaining walls).
In the present study, the control group (G1) showed statistically
significantly higher fracture resistance than all other groups. These results might be explained by the fact that the preservation of tooth structure enhances the fracture resistance under occlusal loads of ETT (8).
Several studies revealed that the sound tooth structure removed during
tooth preparation affects its fracture resistance against loading (23, 24).
On the other hand, the lowest fracture resistance values were found for
G2 (MOD preparation without restoration). These results might be
attributed to the fact that removing tooth structure and leaving it
without restoration will weaken the tooth against loading. Studies
showed that the main factor affecting the survival rate of ETT is
substance loss (25, 26). In addition, the absence of adhesive
restoration might weaken a tooth against the fracture load. Hence,
the purpose of a restoration is not only to fill the cavity but also to
strengthen the tooth and provide an effective seal between the cavity
and mouth (27). G3 presented a higher fracture resistance (482.1 
72.9 N) than G2 (411.8  104.9 N). This finding shows that the restoration of MOD with adhesive resin composites can replace the lost
dentin and recover the resistance of the tooth against the fracture
load to a good extent (21). The mean fracture loads recorded for G3
and G5 (428.1  72.9 N and 656.1  139.4 N, respectively) showed
that resin composites alone (for G3) or horizontal glass fiber post alone
(for G5) were not sufficient to sustain occlusal loads. Better results in

TABLE 2. Fracture Loads (N) (mean  standard deviation)

Group

Mean standard deviation

G1 (control group)
G2 (MOD preparation without restoration)
G3 (MOD preparation with resin composite restoration)
G4 (MOD preparation with composite restoration and horizontal fiber post)
G5 (MOD preparation with transfixed fiber post only)

994.5  147.3A,B
411.8  104.0C
482.1  72.9D
961.3  245.2B
656.05  139.4E

Statistically different means (P # .05) are indicated by different superscript letters.

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Figure 4. Fracture loads (N) required to fracture ETT.

G4 (961.31  245.21 N) were obtained by using both resin composite

and a horizontal glass fiber post when restoring ETPs. These findings
reveal that the extension of a horizontal glass fiber post through the
buccal and palatal cusps strengthens the composite resin filling and
through adhesion reinforces the cusps and enhances the fracture resistance of ETPs.
All groups (except G4) had almost favorable fracture mode, which
means that the fracture occurred in the cervical third of the root, which
is considered a restorable fracture in many clinical instances. This can
be explained by the morphology of the MOD preparations, leaving
limited amounts of residual tooth structure at level of the cervical
margin of the specimens. Another reason could be the low elastic
modulus of composite resin, which can transmit the load to adjacent

dental structures. The concentration of stresses in the thin dentin of cervical area can lead to favorable fracture. Specimens in G4 had almost a
catastrophic fracture mode. This can be explained by the fact that the
presence of a horizontal glass fiber post reinforced the residual tooth
structure in the coronal part. Because the modulus of elasticity of a glass
fiber post is similar to that of dentin and the resin composite (11), the
compressive load will be redistributed and prevented from discharging
on the crown or in the cervical third of root. Therefore, the
stress released was limited to middle and apical thirds of root, and
the fracture occurred as a catastrophic mode. It has been suggested
that glass fiber posts (28, 29) show reduced stress transmission to
the root because of similar elasticity compared with dentin (30, 31).
However, in light of recently published clinical studies showing
higher failure rates with glass fiber posts than with zirconia ceramic
posts and cast posts (32), validity of this concept might be questioned
(32, 33).
In light of the results of this study, presence of a horizontal
glass fiber post can increase the fracture resistance of ETPs against
fracture load. As in many in vitro studies, it is difficult to extrapolate the results of this study directly to a clinical situation. A limitation in this study may be that a single load to fracture test was
incorporated. To mimic the intraoral condition, further studies
should be done with thermocycling and dynamic fatigue loading.
In addition, placing the full coverage on ETT is not only to prevent
fracture but also to prevent leakage that may cause secondary
carious lesions. Composite restorations might be more prone to
this unwanted outcome, especially when large amounts of defects
are replaced with composite that may have significant shrinkage
when cured. In this regard, long-term use of this method should
be followed up in a clinical study.

Conclusions
Figure 5. Fracture mode and frequency of each group.

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Within the limitations of this study, a horizontal glass fiber post in a

MOD cavity increased the fracture resistance of ETPs significantly.

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TABLE 3. Fracture Mode of Each Group
Groups
Fracture mode

G1

G2

G3

G4

G5

Restorable
Non-restorable

10 (83.3%)
2 (16.7%)

6 (50%)
6 (50%)

5 (41.6%)
7 (58.4%)

3 (25%)
9 (75%)

10 (83.3%)
2 (16.7%)

Acknowledgments
The authors deny any conflicts of interest related to this study.

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