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of nonvital teeth
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more direct fiber-reinforced
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The Journal of Adhesive Dentistry, 2009
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Reconstruction of Nonvital Teeth Using Direct
Fiber-reinforced Composite Resin: A Pilot
Papers
Clinical Study
Terms Article in The journal of adhesive dentistry · March 2009
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Tufts University
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Reconstruction of Nonvital Teeth Using Direct Fiber-

reinforced Composite Resin: A Pilot Clinical Study
Simone Deliperia/David N. Bardwellb

Purpose: To evaluate the clinical performance of direct Class II fiber-reinforced composite restorations on nonvital
teeth.

Materials and Methods: Thirty patients age 18 or older were included in this clinical trial restoring 35 molars. The in-
clusion criteria were: two- to four-surface restorations, replacement of composite and amalgam restorations neces-
sary or unrestored teeth with decay reaching the pulp, teeth having homogeneous root canal fillings terminating 0 to
2 mm from the radiographic apex. Teeth with residual cavity walls less than 1 mm or with complete loss of the clinical
crown were excluded. Teeth were restored using a combination of Ultra etch 35% phosphoric acid, PQ1 adhesive sys-
tem, and Vit-l-escence microhybrid composite resin. The enamel peripheral shell of the restoration was built up first; a
resin-impregnated piece of polyethylene ribbon fiber (Ribbond Triaxial) was covered with B1 Perma-Flo flowable com-
posite, placed into a prepared canal, folded, and light cured; then, dentin and enamel occlusal surface stratification
was completed. All 35 restorations were evaluated at 6 months and 1 year by two independent evaluators using mod-
ified USPHS criteria.

Results: No failure was reported and alpha scores were recorded for all parameters. Before starting the treatment,
26 out of 35 teeth (74%) had apical periodontitis as diagnosed radiographically. At the 1-year recall, no signs of peri-
apical lesions were detected and radiographs reported neither periodontal ligament widening nor periapical radiolu-
cency.

Conclusion: Direct fiber-reinforced composite resin restorations demonstrated excellent clinical performance at
1 year.

Keywords: adhesive system, composite resin, Class II restoration, nonvital teeth, post and core, UHMWPE fiber, clini-
cal report.

J Adhes Dent 2009; 11: 71-78. Submitted for publication: 01.04.07; accepted for publication: 14.11.07.

or fracture.12 However, recent motivation to protect and re-

N onrestored nonvital teeth are structurally compro-
mised and represent one of the greatest challenges
for the clinician. More than 15 years ago, the restoration
inforce the remaining sound tooth structure, bolstered by
the properties of modern adhesive systems,22 has encour-
of endodontically treated teeth was automatically associ- aged clinicians to re-evaluate the dogma of traditional
ated with a combination of prefabricated or custom-made restorative dentistry. Looking for alternative methods to
metallic post and cores and full crowns. Various post ma- build up nonvital teeth has become increasingly popular.
terials and designs have been introduced over the years; a Adhesive restorations allow clinicians to create minimally
considerable amount of sound coronal and radicular tooth invasive preparations, thus preserving sound tooth struc-
structure was sacrificed, increasing risk of root perforation ture; interestingly, the cont inuous improvemen t of the
physical and mechanical properties of resin bonded com-
posite (RBC) has encouraged clinicians to progressively
a Adjunct Assistant Professor, Tufts University School of Dental Medicine, abandon amalgam.4 Moreover, patient demand for es-
Boston, MA, USA, and P rivate Practice, Cagliari, Italy.
thetic restorations and desire to preserve remaining sound
b Associate Clinical Professor of Restorative Dentistry, Tufts University School
of Dental Medicine, Boston, MA, USA.
tooth structure have increased dramatically. Lately, den-
tist s have expan ded clinical indi cations for direct RBC
Correspondence: Dr. Simone Deliperi, Via G. Baccelli,10/b, 09126 Cagliari-
Italy. Tel:+39-347-953-3259, Fax: +39-070-302-588. e-mail: restorations. 6,7,16 This situation may be further influenced
[email protected] by a patient’s inability to afford the ideal indirect restora-

Vol 11, No 1, 2009 71

Deliperi and Bardwell

tion in large posterior and anterior situations. As a conse- MATERIALS AND METHODS
quence, clinical indications for anterior and posterior RBC
restorations are progressively increasing. Selection Criteria
Prefabricated tooth-colored fiber-reinforced composite Thirty patients 18 years of age or older were included in
(FRC) posts were introduced in the 1990s and have sev- this pilot clinical trial to reconstruct 35 endodontically
eral advantages over conventional metal posts. 20 They are treated posterior teeth.
esthetic, bond to tooth structure, have a modulus of elas- Only teeth meeting the following criteria were included
ticity sim ila r to that of den tin , but sti ll requ ire dentin in the study:
preparation for canal placement. • MO, DO or MOD Class II restorations (2- to 4-surface
Presently, alternative fiber reinforcement systems have restorations)
been introduced in the attempt to increase RBC durability • replacement of amalgam or composite resin restora-
and damage tolerance; 23 Ultra High Molecular Weight tions necessary because of secondary decay, fracture
Polyethylene (UHMWPE) fiber reinforcement systems are of either the filling material or tooth structure associ-
gaining popularity. Success is enhanced by utilizing bond- ated with periapical lesions, or unrestored teeth with
able reinforcement fibers to build up endo posts and cores decay reaching the pulp
and adapt to the root canal walls without requiring addi- • teeth with one or two missing cusps
tional enlargement of the root canal. These woven fibers • teeth in occlusion and having proximal contact with the
have a modulus of elasticity similar to that of dentin and adjacent teeth
are intended to create a monoblock dentin-post-core sys- • molars
tem, allowing better distribution of forces along the root.19
Recently, improved UHMWPE fiber systems have been in- Patients with occlusal parafunction were not included in
troduced onto the market (Ribbond Triaxial). They have the study. Patients whose teeth showed severe internal
greater strength properties than conventional UHMWPE discoloration (tetracycline stains, fluorosis), smokers, and
fibers because of the unidirectional alignment of fibers either pregnant or nursing women were excluded from the
with braided filaments inserted between. study. Teeth having a remaining cavity wall thickness
Fiber-reinforced composite resins may be based on vari- < 1 mm or with complete loss of the clinical crown were
ous fabric configurations. The types of reinforcement may also excluded (Table 1). Furthermore, patients unable to
consist of unidirectional fibers, UHMWPE biaxial or triaxial attend recall and having a gingival index score greater
braided fibers, and UHMWPE leno-woven fibers. The unidi- than 1 were excluded from the study.
rectional configuration provides significant enhancement Only endodontically treated teeth (see below for de-
of strength and stiffness in the fiber direction, but it has scription of treatment) having homogeneous root canal fill-
poor transverse properties, resulting in the tendency for ings terminating 0 to 2 mm from the radiographic apex
longitudinal splitting and premature failure. Resin-rich and having homogeneous root fillings were included in the
areas may also result from the architecture modification study. Conversely, nonvital teeth with root canal fillings ter-
during handling. Fiber orientation of biaxially braided ma- minating more than 2 mm from the radiographic apex
terial may also change after cutting and embedding in the were excluded.
composite when adapting to tooth contours. The fibers in Informed consent was obtained prior to commence-
the ribbon spread out and separate from each other, loos- ment of the study. All subjects received dental prophylaxis
ening the integrity of fabric architecture. 2 weeks prior to the start of the study. Teeth were restored
In the triaxial braid architecture, fibers are arranged in no later than 2 weeks after we completed endodontic
three directions: the axial yarns and the two braiding yarns treatment.
oriented at predetermined sets of angles (eg, approximately
30 and 45 degrees). Karbhari and Wang 13 reported that the Endodontic Treatment
use of triaxial braids increases the flexural characteristic of A crown-down technique was used for instrumentation; a
composite resin and provides a high level of fatigue resis- 5.25% solution of sodium hypochlorite was used between
tance by isolating and arresting cracks. They also reported each instrument size. The prepared canals were coated
that the maximum flexural stress of dentin was around 60% with a eugenol-based root canal sealer (Pulp canal sealer,
higher than that of the unreinforced composite resin; con- Kerr Sybron;). The vertical condensation technique was ac-
versely, the same braided composite resin provided over complished using heated gutta-percha (System B, Kerr
70% enhancement in maximum stress level. UHMWPE triax- Sybron) to completely fill the root canals. Teeth were tem-
ial braided fibers can be cut and embedded in dental com- porized using a provisional restorative material (Cavit W,
posites with no architectural alteration; the fiber yarns 3M ESPE; St Paul, MN, USA).
maintain their orientation and do not separate from each
other when closely adapted to the contours of teeth. Restorative Procedure
The purpose of this study was to evaluate the clinical Teeth were restored no later than two weeks after complet-
performance of direct fiber-reinforced composite restora- ing endodontic treatment. A rubber-dam was placed and
tions when a microhybrid composite resin was used to re- the cavity prepared in a very conservative manner, remov-
construct severely damaged posterior endodontically ing only decay and/or the existing restoration with a #245
treated teeth. We hypothesized that a 100% composite (ISO #008) bur (Shofu Dental; San Marcos, CA, USA),
resin retention could be expected at the 6-month recall. rounding sharp angles with a #2 (ISO #010) and #4 bur

72 The Journal of Adhesive Dentistry

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Deliperi and Bardwell

(ISO #014) (Shofu). No bevels were placed to the occlusal Table 1 Main characteristics of the cavity preparation
or gingival surfaces (Fig 1). Three to four millimeters of before final restoration
gutta-percha were removed from root canals (distal in
mandibular and palatal in maxillary molars) to expose n
l) io
t
dentin and increase microretention for the enamel/dentin a
n ra e d
adhesive systems. A sectional matrix (Composi-Tight, GDS; a o
p c
( t g e
s s d lv
Spring Lake, MI, USA) was placed on the tooth and inter- u t
n re ri o
c l v
g d e g s g a n s
proximal adaptation was secured using wooden wedges t # n u n i e
n in m n y in i f c
e h o e ti o
i
(Fig 2). Enamel and dentin were etched for 30 s using 35% it t
o
s
s b c s
i v a
c
s
s rg o
. fa
r
phosphoric acid (Ultra Etch, Ultradent; South Jordan, UT, a o
i ib a
l x re e i a o u
P T M R p E p D M m N s
USA) (Fig 3); the etchant was removed and the cavity water 1 46 – D A + M-D 3
sprayed for 30 s, being careful to maintain a moist sur-
face. A fifth generation 40% filled ethanol-based adhesive 2 36 MF D A + M 3
system (PQ1, Ultradent) was placed in the preparation, 3 16 MF MF C + M 3
gently air thinned to evaporate solvent, and light cured for
4 16 MP P A + M 3
20 s at 800 mW/cm 2 from the occlusal surface using an
47 ML D A – M
LED curing light (Ultra-Lume V, Ultradent) (Fig 4).
In order to avoid microcrack formation on the remaining 5 47 DL D – + D 3
facial/palatal wall, the authors used a previously de- 6 37 ML D C + M 4
scribed technique, which is based on a combination of DL
pulse and progressive curing technique5,7 (Table 2).
A particular composite placement technique was also 7 26 – P – + M 2
selected to build up the restorations. Vit-l-escence microhy- 8 46 DL D A – D 3
brid RBC (Ultradent) was considered the material of choice
9 26 P P A M-D 3
to restore the nonv ita l teeth becaus e of its var iety of
enamel shades and excellent mechanical properties. 7 The 10 26 DP P A D 3
sectional matrix was burnished against the adjacent teeth. 11 46 – D A – M-D 3
Tooth buildup was started using 2-mm wedge-shaped, gin-
12 36 DL D A + D 3
givo-occlusally placed layers of amber (PA) and smoke (PS)
enamel shades to reconstruct the proximal and palatal 13 46 MF D A – M 3
surfaces. This uncured composite was condensed and 14 27 MP P A + M 3
sculptured against the cavosurface margins and sec-
15 46 DF D A + M-D 4
tional matrix; each increment was pulse cured for 3 s at
800 mW/cm2 to avoid microcrack formation. Final poly- 47 ML D A + M 3
merization of the PA and PS composite proximal and 16 37 MF D A + M 3
palatal/facial walls was then completed at 800 mW/cm 2 16 DP P A – D 3
for 20 s. The enamel peripheral skeleton of the restoration
17 26 MF P A + M 3
was built up, providing more spatial references to create a
correct occlusal anatomy (Fig 5). A UHMWPE triaxial fiber 18 36 DL D A + D 3
(Ribbond; Seattle, WA, USA) was selected and manipu- 19 27 DP P C – D 3
lated according to manufacturer’s instructions. Triaxial
fibers were wetted with an unfilled resin (Permaseal, Ultra- 20 16 DP D A – D 4
DF
dent), resin excess was removed, the fibers completely
covered with a B1 light-curing flowable composite resin 21 36 DL D C + D 3
(Permaflo, Ultradent) and placed in the central area of the
22 26 DP P A – D 3
restoration. UHMWPE triaxial fibers were folded and each
end pushed in the root canal using a thin composite spat- 23 26 DP P C + D 3
ula6 (Fig 6). The fiber-resin complex and flowable compos- 24 27 – P A – M-D 3
ite resin were light cured at 800 mW/cm 2 for 120 s to
25 47 – M C – D 2
assure complete polymerization of the fiber-composite
resin complex down into the canal. Dentin stratification of 26 26 – P A – M-D 3
the facial, palatal, and proximal walls was initiated, placing 46 ML D A + M 3
2-mm wedge-shaped increments of A3 RBC onto each 27
36 MF D A + M 3
enamel wall, avoiding contact with fresh increments. Suc-
cessive A4 and A3.5 increments were placed in the 37 DL D C + D 3
28
16 DP P – – D 3
central area of the restoration, surrounding the resin- im-
pregnated fiber-composite system to increase the chroma, 29 17 MP P – + M 3
unnaturally reduced by previously using B1 flowable com-
30 36 – D A + M-D 3
posite; a direct post and core was created. Each dentin in-
crement was cured using a progressive “curing through” Abbreviations: M: mesial; D: distal; F: facial; L: lingual; P: palatal; A: amalgam;
C: composite.

Vol 11, No 1, 2009 73

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