journal of the mechanical behavior of biomedical materials 118 (2021) 104440

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Journal of the Mechanical Behavior of Biomedical Materials

journal homepage: http://www.elsevier.com/locate/jmbbm

Fatigue failure of anterior teeth without ferrule restored with

individualized fiber-reinforced post-core foundations
Márk Fráter a, 1, *, Tekla Sáry a, 1, Gábor Braunitzer b, Balázs Szabó P.c, Lippo Lassila d,
Pekka K. Vallittu d, e, Sufyan Garoushi d
a
Department of Operative and Esthetic Dentistry, Faculty of Dentistry, University of Szeged, Szeged, Hungary
b
DicomLAB Dental Ltd., Szeged, Hungary
c
Department of Food Engineering, Faculty of Engineering, University of Szeged, Szeged, Hungary
d
Department of Biomaterials Science and Turku Clinical Biomaterials Center -TCBC Institute of Dentistry, University of Turku, Turku, Finland
e
City of Turku Welfare Division, Oral Health Care, Turku, Finland

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: The aim was to explore the survival of extensively damaged anterior teeth without ferrule restored
Fatigue survival with different fiber-reinforced composite (FRC) post-core foundations and composite crowns.
Post-core foundation Materials and methods: Sixty extracted upper central incisors were decoronated and randomly divided into four
Short fiber-reinforced composite
groups (n = 15). After endodontic treatment, the specimens were restored with different individualized fiber-
Individualized post
reinforced post-core foundations as follows: control group (CTRL): multiple unidirectional FRC-post + dual-
cure composite-core, PFC: multiple unidirectional FRC-post + packable short fiber-reinforced composite (SFRC),
BPFC: Bioblock technique with only packable SFRC, BFFC: Bioblock technique with only flowable SFRC. After
core build-up, the teeth were finalized with adhesively luted CAD/CAM composite crowns. Cyclic isometric
loading (5 Hz) was applied at 100 N for 5000 cycles, and then 200 N and 300 N for 15,000 cycles each in a fluid
chamber. The specimens were loaded until fracture occurred or when a total of 35,000 cycles were reached.
Kaplan-Meyer survival analysis was conducted, followed by pairwise log-rank post hoc comparisons (Mantel-
Cox).
Results: The survival rates of the control (8279 cycles) and PFC (6161 cycles) were significantly higher compared
to BPFC (3223 cycles) and BFFC (2271 cycles) (p < 0.05). Regarding fracture pattern, nearly all specimens
fractured in a restorable manner.
Conclusions: For restoring extensively damaged anterior teeth, multiple unidirectional FRC posts are
recommended.
Clinical relevance: Although different FRC post/core systems are available for the restoration of damaged root
canal treated anterior teeth, multiple unidirectional FRC posts tend to be a good option when the ferrule is
missing.

1. Introduction et al., 2018). Post placement is advised in anterior teeth when less than
50% of the crown remains (Zarow et al., 2018; Meyenberg, 2013a). One
Root canal treated (RCT) teeth usually need significant build-up with of the key elements influencing the success of post-restorations is the
various post-core materials to help the retention of the full crown presence or absence of a 1.5–2 mm high coronal dentin after prepara­
restoration (Lassila et al., 2019). Post usage is determined by the amount tion, known as the “ferrule”.
of residual coronal structure and the internal root structure. The primary The purpose of the ferrule is to redistribute the occurring stress on
purpose of a post is to provide retention when the residual coronal the outer coronal third of the root, therefore possibly shifting the frac­
structure is inadequate to retain the core material (Santos Pantaleón ture pattern to a restorable one (Fragou et al., 2012).

* Corresponding author. Chair of the department Department of Operative and Esthetic Dentistry Faculty of Dentistry University of Szeged Tisza Lajos Krt. 64 H-
6720, Szeged, Hungary.
E-mail address: [email protected] (M. Fráter).
1
Márk Fráter and Tekla Sáry contributed equally to this work.

https://doi.org/10.1016/j.jmbbm.2021.104440
Received 22 December 2020; Received in revised form 6 February 2021; Accepted 26 February 2021
Available online 3 March 2021
1751-6161/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M. Fráter et al. Journal of the Mechanical Behavior of Biomedical Materials 118 (2021) 104440

Studies have shown that the presence of a ferrule is of high impor­ group in fatigue resistance, or (2) in their fracture pattern.
tance (Santos Pantaleón et al., 2018; Lazari et al., 2018; Magne et al.,
2016). However, restoring RCT anterior teeth can be a challenge when 2. Materials and methods
there is no ferrule (Saker and Özcan, 2015). Possible approaches to such
a situation involve surgical crown lengthening and orthodontic extru­ The Ethics Committee at the University of Szeged approved this
sion. However, many times patients are unwilling to undergo these in­ study as it was planned in according to the declaration of Helsinki. All
terventions and only allow restorative procedures. materials adapted in this study are made by the same manufacturer and
In such situations, choosing the adequate type of post is a key used according to the instructions of use.
element of success. Of the different post materials, glass fiber-reinforced Intact maxillary central incisors extracted for periodontal causes
composite (FRC) posts stand out with their favourable biomechanical were collected for this research. The newly extracted maxillary central
characteristics and ability to enhance light transmission through the incisors were directly inserted for only 5 min in sodium hypochlorite
root canal space (Saker and Özcan, 2015). FRC posts contain long uni­ (5.25%) and then kept in solution of saline (0.9%) for a maximum 8
directional fibers encapsulated with resin matrix of epoxy or weeks at room temperature before use. After extraction, with the aid of
mono/di-methacrylate. Depending on the resin system, there are two hand scalers, the root surface was cleaned from the covered soft tissue.
main type of FRC posts: regular FRC posts with a predefined shape Sixty upper central incisors having equal mesiodistal and buccolingual
containing fully-polymerized and highly cross-linked polymer matrix, dimensions and root length of 13 mm were chosen. On the basis of the
and individually-made FRC posts which contain nonpolymerized resin measurements, only teeth with a maximum deviation of 10% from the
matrix which forms a semi-IPN matrix after curing (Vallittu and Özcan, determined mean were included in this study.
2017). Some studies have shown that FRC posts decrease the incidence Before performing root canal treatment, diamond disc with water
of catastrophic fractures (Mohammadi et al., 2009), however, other cooling was used to section all crowns horizontally at the level of the
studies found no difference (Figueiredo et al., 2015) or even the opposite cementoenamel junction (CEJ). ProTaper Universal files (S1, S2, F1, F2)
(Magne et al., 2017) regarding the fracture pattern. (Dentsply Maillefer, Ballaigues, Switzerland) were used for cleaning and
It should be emphasized that anterior teeth restored with a post have shaping of the root canals. Irrigation with sodium hypochlorite (2.5%)
a fracture rate that is 3 times higher compared to posterior teeth (Garcia was applied during instrumentation. After the instrumentation phase,
et al., 2019). This could partly be attributed to the higher horizontal alcohol (96%) and paper points were used for drying the root canals.
forces that these teeth are exposed to because of their position in the Single cone obturation technique was performed for root canal filling
arch. Once greater horizontal forces are present, the post-root canal using a master cone (F2 gutta-percha, Dentsply Maillefer) and sealer
interface is challenged, and any potential flaw can later progress into (AH plus, Dentsply Maillefer). Fuji Triage Pink (GC Europe, Leuven,
failure. In case of FRC posts, loss of retention or post fracture are the Belgium) was used as temporary filling and also applied on the root tip
most frequent types of failure (Zicari et al., 2012). The reasons are with the purpose of preventing apical leakage. The filled roots were kept
manifold, including the assumed weakening of the root during post in an incubator (mco-18aic, Sanyo, Japan) for 7 days (100% relative
space preparation, the inaccurate fit of the post due to the irregular humidity, 37 ◦ C). Before the post space preparation the decoronated flat
geometry and cross section of the root canal, or the inability of the post surface of the root was roughened with a diamond bur. All roots ob­
material to adequately bond to the luting or core build-up material. This tained a post space preparation (minimal invasive) with a 7 mm depth
later one could be solved by the usage of individually-made FRC posts measured from the orifice, but no post preparation drills were used so
(everStick Post, GC Europe) containing polymethyl methacrylate that the individual anatomy of the root canal can be maintained. ISO
(PMMA) resin, which insures proper and durable bonding to the lutin­ standard Hedstrom files (Dentsply Maillefer) and Number 3 Gates
g/and or core build-up resin material (Bell-Rönnlöf et al., 2019). Vallittu Glidden burs (Dentsply Maillefer) were used to remove only the gutta­
concluded that the amount and adaptation of fibers in the critical cer­ percha and leaving a minimum apical seal of 5–6 mm in the canal. Once
vical part of the tooth could determine the success of restorative pro­ the post space was ready, the root canal was washed with chlorhexidine
cedures involving post insertion (Vallittu, 2016). Should the post fail to and dried with paper points.
fit well, particularly at the coronal level, the resin cement film will be In the control (CTRL) and PFC groups, an individualized FRC post
too thick; this favours bubble formation, which may result in post was directly created in the canal as described by Hatta et al. (2011). The
de-bonding. A way to overcome this problem is to fabricate individu­ root canal received as many fiber bundles (0.9-mm-sized) of uncured
alized posts that aim to maximize the amount of fibers and minimize the FRC posts (everStick POST, GC Europe) as possible, to exactly fit the
amount of luting material in the root canal, thus providing an ideal individual cross-section of the root canal. These posts were gently
fitting of the post irrespective to the unique cross-section of the root removed from the root canal as one unit with a needle-nose plier and
canal. One clinically relevant option is to make an individualized FRC then light cured for 40 s.
post from multiple unidirectional FRC posts (Hatta et al., 2011; Fráter Same adhesive treatment was used for all teeth. According to the
et al., 2017). Another possibility is to fabricate the post and core manufacturer’s instructions a dual-cure one-step self-etch adhesive
build-up directly from short fiber-reinforced composites (SFRC) inside system (Gradia Core Self-Etching Bond, GC Europe) was applied. Suction
the root canal (Garoushi et al., 2009; Forster et al., 2016; Fráter et al., tip and paper point were used to remove the excess adhesive. An Optilux
2020a). In the Bioblock technique, both the root canal space and the 501 quartz-tungsten-halogen light-curing unit (Kerr Corp., Orange, CA,
coronal cavity are filled with conventional or packable SFRC in 4–5 mm USA) was used to light cure (60 s) the adhesive. The average power
thick horizontal increments (Fráter et al., 2020a, 2020b). In 2019, the density of the light-curing unit, which was justified with a digital radi­
flowable form of SFRC was introduced with the promise of easy adapt­ ometer (Jetlite light tester; J. Morita USA Inc. Irvine, CA, USA) was 900
ability in limited spaces (such as root canals). mW/cm2. After light curing the adhesive, the specimen were distributed
The question arises whether one may use just any version of SFRC for among 4 groups according to the different individualized fiber rein­
post and core to restore RCT anterior teeth in the absence of ferrule or forced post-and-core techniques. The teeth were restored as follows
unidirectional long fibers (in the form of FRC posts) are preferable. To (Fig. 1):
the authors’ best knowledge, this is not well documented in literature. CTRL: The teeth received an individualized FRC post fabricated from
Thus, unlike previously published research, the purpose of this in vitro 2 to 3 pieces of FRC posts as previously described. Following the man­
study was to investigate the fatigue resistance and failure patterns of ufacturer’s instructions the surface of the individualized post was acti­
RCT anterior teeth without a ferrule restored with different FRC mate­ vated with pure resin (Stick Resin, GC Europe). Luting of the
rials and crowns. The null hypotheses were that (1) the tested individ­ individualized posts and the core build-up was performed with a dual-
ualized FRC post and core techniques would not differ from the control cure resin composite core material (Gradia Core, GC Europe). After

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M. Fráter et al. Journal of the Mechanical Behavior of Biomedical Materials 118 (2021) 104440

Fig. 1. Schematic figure representing the test groups. CTRL: Individually-made unidirectional FRC post + Gradia Core; PFC: Individually-made unidirectional FRC
post + packable SFRC core; BPFC: Bioblock technique with packable SFRC; BFFC: Bioblock technique with flowable SFRC.

the insertion of the post, 5 min of autopolymerization time was given to was taken of each prepared specimen. The impressions were molded and
decrease polymerization stress. Subsequently the build-up was light the models underwent digital scanning using the Cerec CAD/CAM sys­
cured for 40 s from each side (a total of 160 s/tooth). tem (Sirona Dental Systems GmbH, Bensheim, Germany) and restora­
PFC: The teeth received an individualized FRC post, fabricated in the tions were designed using the 4.4 Cerec software. Nanofilled composite
same way as in the control group. Luting of the individualized posts was resin anterior crowns (Cerasmart, GC Europe) with standardized di­
performed the same way as in the control group, but the core build-up mensions and thickness were milled and carefully adjusted to the pre­
around the post was performed with SFRC (everX Posterior, GC pared specimen under optical microscopy (Carl Zeiss Technical
Europe) packed around the post using approximately 3-mm-thick hori­ Stereomicroscope, Germany), and polished.
zontal increments. Each increment was light cured from the side for 40 s At the luting phase, the fitting surface of the composite crowns was
(a total of 160 s/tooth). sandblasted, rinsed and ultrasonically cleaned (Emag, Valkenswaard,
BPFC: The teeth were restored with the Bioblock technique described Netherlands) in distilled water for 5 min. After drying the surface, the
by Fráter et al. (2020a), building a direct layered post and core from fitting surface was treated with a special silane (G-Multi Primer, GC
packable SFRC (everX Posterior). An approximately 4 mm thick incre­ Europe). The prepared core was sandblasted and adhesively treated with
ment of SFRC was packed into the apical portion of the post space using a self-etch universal adhesive (G-Premio Bond, GC Europe). The adhe­
a microbrush-X disposable applicator (Pentron Clinical Technologies, sive was thinned out and photopolymerized for 60 s. The crowns were
LLC, USA). A short piece of light-transmitting FRC post (1.2 mm GC adhesively luted with a dual-cure adhesive resin cement (G-CEM Link­
Fiber post, GC Europe) was inserted into the post space with the aim of Force, GC Europe). The luting agent was applied into the fitting surface
aiding the transmission of the light to the apically placed layers. As of the restoration and the crowns were positioned on the prepared cores
described in the Bioblock technique (Fráter et al., 2020a) the under finger pressure until they reached their final position. After
light-transmitting post was positioned 0.5–1 mm coronally from the ensuring that all excess material had been removed, glycerine gel (DeOx
surface of the uncured SFRC layer. After each layer, 80 s of light curing Gel, Ultradent Products Inc., Orange, CA, USA) was applied and pho­
through the fiber post followed. After incrementally filling the root canal topolymerization was performed from each side for 40 s with Optilux
to the level of the CEJ, SFRC was layered to form the core build-up. Each 501. All teeth after luting of the crown had a standardized coronal
coronally placed increment was light cured from the occlusal direction cervical-incisal length between 8 and 8.5 mm.
for 40 s. The restored specimens were kept wet (Isotonic Saline Solution
BFFC: The teeth were restored with flowable SFRC (everX Flow, GC 0.9%; B. Braun, Melsungen, Germany) in an incubator (37 ◦ C). The root
Europe) as described in BPFC. surface of each specimen was coated with two layers of liquid latex
After the post and core build-ups all cores were finalized according to separating material (Rubber-Sep, Kerr, Orange, CA, USA) prior to
the protocol of Maroulakos et al. (2015). All cores were prepared 3 mm embedding for mimicking the periodontal ligament. To simulate the
incisal to the finish line lingually and 6 mm incisal to the finish line bone level, the restored teeth were embedded in methacrylate resin
buccally. This simulated a central incisor preparation having no (Technovit 4004, Heraeus-Kulzer, Germany) at 2 mm from the cemen­
remaining tooth structure above the prepared finish line. The finish line toenamel junction (CEJ). For mechanical testing, the restoration-tooth
was a 1 mm wide circumferential shoulder prepared with a flat-end, units were submitted to an accelerated fatigue-testing protocol,
medium grit, tapered diamond (847/018; Brasseler). After finalizing described by Lazari et al. (2018), performed with a hydraulic testing
the preparation, polyether impression (Permadyne, 3M ESPE, Germany) machine (Instron ElektroPlus E3000, Norwood, MA, USA). The

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M. Fráter et al. Journal of the Mechanical Behavior of Biomedical Materials 118 (2021) 104440

specimens were tested at an angle of 135◦ to the long axis of each tooth significant (p > 0.05) difference in terms of survival between CTRL and
in a fluid chamber filled with saline in order to simulate oral conditions PFC groups, and also between BPFC and BFFC groups. Regarding the
as much as possible. Cyclic isometric loading was applied on the incisal fracture pattern, all specimens showed a restorable type of fracture
edge of the tooth using a 1 cm wide, flat ended metallic tip. Cyclic load except PFC group that had one specimen presenting a nonrestorable
was applied at 5 Hz, starting with gradually increasing static loading fracture type (Fig. 3).
until 100 N in 5 s, followed by cyclic loading at 100 N for 5000 cycles,
and then at 200 N and 300 N, for 15,000 cycles each. The specimens 4. Discussion
were loaded until fracture occurred or when a total of 35,000 cycles
were reached. For the survival analyses, the total number of pre-failure Endodontically treated teeth without adequate ferrule pose consid­
cycles was recorded. After the loading test all specimens were inspected erable therapeutic challenge, and the selection of the correct post type
under optical microscope and the failure mode was evaluated. Distinc­ could be a key element in the success of the treatment (Maroulakos et al.,
tion was made between restorable or nonrestorable fractures with a 2015). In this study, different individualized FRC post-and-cores were
two-examiner agreement. A restorable fracture was defined as a fracture used with the purpose of reinforcing anterior teeth without ferrule. Our
that ends above the CEJ, whereas a nonrestorable fracture extends hypotheses are partially rejected, as there was a significant difference
below the CEJ. This means that the fractured tooth can be restored and found in fatigue resistance performance among the restorative tech­
kept in the mouth in case of a restorable fracture, while in case of a niques used (Fig. 2). However, there were no differences in fracture
nonrestorable one the tooth is likely to be extracted. pattern between the groups.
Statistical analysis was performed in SPSS 23.0 (IBM Corp., Somers, During the mechanical testing, cyclic loading was applied according
NY, USA). Kaplan-Meyer survival analysis was conducted, followed by to an accelerated fatigue testing protocol (Lazari et al., 2018; Magne
pairwise log-rank post hoc comparisons (Mantel-Cox). et al., 2016). Cycling fatigue loading simulates the clinical situation
better than static loading, as it generates cyclic forces similar to normal
3. Results masticatory forces. Moreover, frequently acting cyclic forces induce root
fracture more often than static forces. This protocol (accelerated fatigue)
The Kaplan–Meier survival curves are presented in Fig. 2. Table 1 was introduced as a rational middle ground between the load to fracture
shows the descriptive characterization of the survival as the mean and test and the more sophisticated and time-consuming fatigue tests. By
median number of survived cycles for each tested group. Table 2 dis­ convention, the specimens were loaded at 135◦ to mimic the chewing
plays the p values for group-wise comparisons. There was no statistically forces applied on the palatal surface of an upper anterior tooth.

Fig. 2. Fatigue resistance survival curves (Kaplan-Meier survival estimator) for all four groups. Individually-made unidirectional FRC post + Gradia Core (CTRL);
individually-made unidirectional FRC post + packable SFRC core (PFC); Bioblock technique with packable SFRC (BPFC); Bioblock technique with flowable
SFRC (BFFC).

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M. Fráter et al. Journal of the Mechanical Behavior of Biomedical Materials 118 (2021) 104440

Table 1
The mean and median number of survived cycles for each tested group.
Groups Meana Median

Mean cycles Std. Error 95% Confidence Interval Median cycles Std. Error 95% Confidence Interval

Lower Bound Upper Bound Lower Bound Upper Bound

CTRL 8279,73 1788,27 4774,73 11,784,74 5045,00 39,93 4966,73 5123,27

PFC 6161,60 1057,79 4088,34 8234,86 5031,00 19,32 4993,13 5068,87
BPFC 3223,47 572,68 2101,01 4345,93 4999,00 1941,20 1194,25 8803,75
BFFC 2271,33 576,69 1141,02 3401,64 2296,00 1359,61 ,00 4960,84
a
Estimation is limited to the largest survival time if it is censored.

Table 2
p values of pairwise log-rank post-hoc comparisons among tested groups (Kaplan-Meier survival estimator followed by log-rank test for cycles until failure or the end of
the fatigue loading).
Groups CTRL PFC BPFC BFFC

Chi-Square Sig. Chi-Square Sig. Chi-Square Sig. Chi-Square Sig.

CTRL 0.770 0.380 9.598 0.002 13.213 0.000

PFC 0.770 0.380 10.383 0.001 13.889 0.000
BPFC 9.598 0.002 10.383 0.001 0.911 0.340
BFFC 13.213 0.000 13.889 0.000 0.911 0.340

restored with individualized unidirectional FRC posts (CTRL and PFC

groups) showed significantly higher survival than the ones restored with
the Bioblock technique (BPFC and BFFC) (p < 0.05).
In the Bioblock technique, SFRC is directly and tightly adapted to the
walls of the root canal, excluding the drawbacks of using luting cement.
In addition, the fibers are correctly placed from a biomechanical point of
view, thereby reducing all damaging tensile stresses when the restora­
tion is loaded (Fráter et al., 2020a). Our current results contradict the
previous findings of Garoushi et al. (2009), who found no difference in
fracture resistance when anterior decoronated teeth were restored with
FRC post or with SFRC post and core (an early version of the Bioblock
technique). It must be noted that in the latter study, the post was a
conventional FRC post which was not individualized in any way. Our
findings also seem to contradict the results of Bijelic et al. (2013), but in
their study the tested anterior teeth had an adequate ferrule.
Furthermore, our present findings contradict our previous results
where the Bioblock technique outperformed the individualized unidi­
rectional FRC posts (Fráter et al., 2020a). The difference may be due to
the different clinical situations (anterior no ferrule vs. premolar MOD
cavity), implying different amounts of dentin in the coronal aspect. In
the case of anterior teeth without a ferrule, teeth restored with the
Bioblock technique showed similar survival, regardless of whether
packable or flowable SFRC was used. This is in line with our earlier
results (Fráter et al., 2020b). Flowable SFRC has at least as favourable
Fig. 3. Photographs of various restorable fracture patterns (no tooth fracture)
mechanical properties (e.g. fracture toughness, flexural strength, degree
of crown specimens. (A & B) adhesive failure at interfaces presented in CTRL
of conversion, etc.) as packable SFRC (Lassila et al., 2018) with the
and PFC groups. (C) adhesive failure with post fracture presented in BPFC and
benefit of easier adaptation. Also, flowable SFRC could be used to lute
BFFC groups.
posts inside the root canal, which is an aspect not tested in the present
study.
In our study, the control (CTRL) and PFC groups were restored with
Comparing the two groups restored with unidirectional multiple FRC
long fibers in the form of individualized unidirectional FRC posts, while
posts, SFRC as a core build-up (PFC) did not turn out to be superior to
BPFC and BFFC were restored with short fibers in the form of packable or
using the non-fiber-reinforced core build-up material (CTRL). This is
flowable SFRC. The benefits of using multiple posts compared to single
contrary to the findings of Lassila et al., where the usage of SFRC as core
ones have been demonstrated by many (Hatta et al., 2011; Fráter et al.,
build-up beside an FRC post resulted in superior fracture resistance
2017; Garoushi et al., 2020; Maceri et al., 2007). Maceri et al., have
(Lassila et al., 2019). Our findings are in accordance with those of Lazari
shown that a multipost technique will potentially enhance resistance to
et al., who did not manage to demonstrate difference in survival rates
long-term cyclic loading and decrease pull-out risk (Maceri et al., 2007).
when comparing different core build-up materials next to FRC posts in
In the study of Hatta et al. (2011), and also in one of our previous studies
anterior teeth without ferrule (Lazari et al., 2018). The same was found
(Fráter et al., 2017), applying multiple unidirectional FRC posts to form
by da Silva et al. (da Silva et al., 2010). Our findings can be explained
an individualized FRC post in a root canal resulted in higher fracture
from multiple different perspectives. First, the amount of SFRC used in
resistance in comparison to a single FRC post. As individualized posts
PFC was minimal as multiple unidirectional FRC posts were used not
perform better than single ones in vitro, they also show promising results
leaving much space for the SFRC. Second, the use of long unidirectional
clinically (Garoushi et al., 2020). In this investigation, specimens

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M. Fráter et al. Journal of the Mechanical Behavior of Biomedical Materials 118 (2021) 104440

fibers seems to be of key importance in the given clinical situation. regarding the withstood maximal forces fit well into the range of forces
Continuous unidirectional fibers in the form of FRC posts provide an developing in the anterior region during actual chewing (Figueiredo
anisotropic effect with high strength in one direction and are suitable for et al., 2019).
applications where the highest stress is known to occur (Başaran et al., Another shortcoming could be the accelerated fatigue test used
2013). SFRC contains randomly oriented short fibers, which leads to an within this study. While this test could be positioned in terms of its
isotropic behavior and multidirectional reinforcement, but at the cost of clinical relevance between the lower value static load-to-fracture test
decreased strength in any one direction compared to unidirectional fi­ and the most valid fatigue test, many studies have used this method to
bers (Başaran et al., 2013). Based on this preliminary investigation, gather important information on restoration survival both in vital and
placement of an individualized unidirectional FRC posts significantly root canal treated teeth (Lazari et al., 2018; Magne et al., 2017; Goldberg
improve the fatigue resistance of damaged anterior teeth without et al., 2016). Non-accelerated fatigue testing would be beneficial with
ferrule, despite the type of core material. the same study setup in the future.
In this study, all individualized FRC posts were placed 7 mm deep
into the root canal. According to Meyerberg clinically it could be enough 5. Conclusions
to have 7 mm of FRC post inserted intraradicularly with an approx. 4
mm of the post providing coronal retention to the core build-up For the restoration of extensively damaged anterior teeth without
(Meyenberg, 2013b). Some studies have shown that the length of the ferrule, the use of multiple long unidirectional FRC posts demonstrated
FRC post did not influence the fracture resistance of anterior root canal better performance than SFRC in reference to fracture-behavior. Once
treated teeth restored with a crown (Ramírez-Sebastià et al., 2014; multiple unidirectional fibers are used the core build-up material does
Chuang et al., 2010). Also the post length in case of FRC posts did not make a difference.
influence the generated mvM stresses in anterior teeth upon loading
(Dejak and Młotkowski, 2013). This was further justified by Santos-Filho Author contributions
and colleagues (Santos-Filho et al., 2014). Individualized posts have
better fitting in the critical cervical part of the canal and a better Márk Fráter – Conceptualization, preparation of samples
fiber/luting cement ratio compared to prefabricated FRC posts. Thus, Tekla Sáry - Conceptualization, preparation of samples
the increased width of individualized FRC posts can potentially Gábor Braunitzer – statistical analysis, data curation
compensate the reduced post insertion depth used in this study. It has Balázs Szabó P. – validation, software
been emphasized by many that the effect of post diameter is more Lippo Lassila – methodology
important compared to post length from a biomechanical point of view Pekka Vallittu – review and editing
(Okamoto et al., 2008; Wang et al., 2016). The reason behind is that post Sufyan Garoushi – methodology, writing and editing, supervision
diameter weighs more in resisting bending forces than the length of the Márk Fráter and Tekla Sáry contrebuted equally to this work.
post in the root canal (Wang et al., 2016).
Regarding the fracture pattern, nearly all specimens presented a Funding
restorable type of fracture with no tooth fracture (only one non­
restorable fracture in PFC group), which contradicts the findings of This study was supported by the research activity of BioCity Turku
Lazari et al. (2018). All of the fractures happened in the form of the core Biomaterials Research Program in Turku, Finland and by the ÚNKP-20-
build-up together with the crown detached from the tooth surface, 3-SZTE, ÚNKP-20-5-SZTE New National Excellence Program of The
which suggests adhesive failure. When long unidirectional fibers were Ministry for Innovation and Technology from the Source of National
used (CTRL and PFC) failures presented as a wide gap lingually at the Research, Development and Innovation Fund, Hungary.
interface between the tooth and the restoration without post fracture
(Fig. 3 A&B). This kind of failure has been reported in previous studies Ethical approval
by Lazari et al. (2018), and Magne et al. (2017). Such a failure was also
observed in other studies on endodontically treated molars restored with This article does not contain any studies with human participants or
fiber posts (Magne et al., 2016). From a clinical point of view, this type animals performed by any of the authors.
of failure is extremely critical because it is difficult to detect, can initiate
bacterial contamination of the root-canal system, and can be a potential Informed consent
cause of periodontic and endodontic failure (Saunders and Saunders,
1994). This could be attributed to the flexibility of the FRC post, sug­ For this type of study, formal consent is not required.
gesting that a flexible post allows too much movement of the core,
resulting in increased microleakage under the crown. On the other hand, Declaration of competing interest
when SFRC was used to fabricate the post and core build-up (BPFC and
BFFC), failures presented as restoration detached from the tooth surface The authors declare the following financial interests/personal re­
with post fracture (Fig. 3C). Most likely, the generated stresses at the lationships which may be considered as potential competing interests:
interface (cervical) were exceeding the toughening capability of SFRC. Author Márk Fráter declares to have no conflict of interests. Author
Within this study setup, the tested specimens fractured at relatively Tekla Sáry declares to have no conflict of interests. Author Gábor
low levels of loading, in the 100–200 N range. This could be traced back Braunitzer declares to have no conflict of interests Author Balázs Szabó
to multiple factors. One of these is that the specimens were loaded at the P. declares to have no conflict of interests. Author Lippo Lassila declares
incisal edge, which is admittedly a shortcoming of our setup. More to have no conflict of interests. Author Pekka Vallittu consults for Stick
importantly, this low resistance (also reflected in the low number of Tech - Member of GC Group in R&D and training. Author Sufyan Gar­
survived cycles) could be attributed to the total absence of ferrule in our oushi declares to have no conflict of interests.
specimens, which has been shown to cause great reduction in fracture
resistance or survival (Santos Pantaleón et al., 2018; Magne et al., 2016; Acknowledgment
Saker and Özcan, 2015). According to Laurell et al., the mean maximum
occlusal force is 200–228 N in the anterior region (Laurell and Lundgren, we would like to thank the valuable help of Árpád Schindler.
1984). Regalo et al., reported the mean maximum incisor occlusal force
to vary between 93 and 206 N (Regalo et al., 2008). Irrespective of the
lower number of survived cycles compared to other studies, our results

6
M. Fráter et al. Journal of the Mechanical Behavior of Biomedical Materials 118 (2021) 104440

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