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CLINICAL IMPLICATIONS
In this in vitro study, the static initial strength of inlay-retained fiber-reinforced fixed partial
dentures exceeded 900 N, which is reported as the maximum occlusal force in the molar region.
The weakest features of such restorations remain the pontic area and the low resistance of the
veneering resin composite against occlusal forces.
quantity of fibers, and the direction, orientation, location, principles have been introduced.26 These instruments
construction, distribution, and position of the fibers.4,5 are coated with diamond on only one side, which helps to
Clinicians are expected to satisfy the expectations of guide the instrument at the proximal areas, preventing
patients who seek safe, biocompatible, affordable, and accidental damage of the adjacent tooth as may occur
esthetic restorations. However, clinicians are restricted with rotary instruments. Moreover, the coated side has
by factors such as type of preparation, fiber frame design, a defined shape; for example, it is possible to prepare re-
span length, and the resin composite or luting agent.6 producible preparations with excellent margins.27
The few reports of successful use of FRC This in vitro study evaluated whether a standardized
restorations in the peer-reviewed literature include clinical approach to box preparation using ultrasonic burs
reports7-8 and a study with short-term follow-up.9 The would have an effect on the initial and final failure
primary failure types identified were either bulk fracture strengths and failure locations of inlay-retained FRC
at the connector or pontic area, debonding of the ve- FPDs compared with the conventional preparation
neering composite, or fiber exposure. technique using conventional inlay burs. Also, the fail-
FRC restorations are expected to withstand mastica- ure type and behavior of crack formation was evaluated
tory forces. Different testing methods and the difficulty with an acoustic emission test by recording audible
in measuring masticatory forces result in a wide range of sounds of cracking.
force values. Stress applied during mastication may
range between 441 N and 981 N, 245 N and 491 N,
MATERIAL AND METHODS
147 N and 368 N, and 98 N and 270 N in the molar,
premolar, canine, and incisor regions, respectively.10 A The experimental design consisted of in vitro simula-
restoration should be able to withstand stress to approx- tion of a typical clinical scenario in the mandibular right
imately 500 N in the premolar region and 500 N to 900 quadrant. Forty-two caries-free, restoration-free human
N in the molar region.10 mandibular right first premolars (N = 21) and first
The mode of fracture is a good indicator of the path molars (N = 21) were embedded in autopolymerized
of crack propagation.11-14 In general, stress concentra- poly(methyl methacrylate) (Palapress Vario; Heraeus
tions within the resin and the interface are relieved by Kulzer, Hanau, Germany). A distance of 7 mm was es-
initiation of a crack and propagation of the crack tablished between the 2 abutment teeth. The teeth
through the resin until it meets the fiber,15 resulting in were stored in 0.01% n-chloro-para-toluene sulfon-
debonding of the resin composite. Failure of the FRC amide sodium salt (Chloramine-T; H&S Chemical Co,
due to external force may occur by the cracking of the Covington, Ky) for approximately 3 months prior to
polymer matrix, the fiber, or the interface.16,17 the experiment.
Internal cracking and fracturing of material can be Two operators prepared the teeth, one using the con-
evaluated by means of acoustic emission (AE) signals ventional inlay burs and the other using ultrasonic tips.
from the material.18-20 AE, also known as ‘‘stress wave The first operator did not know the aim of the study
emission,’’ is the term that describes the acoustic stress but was instructed to make the preparations for the pur-
waves that result when energy is rapidly released due pose of placing a direct inlay-retained FRC FPD using
to the occurrence of microstructural changes in a mate- conventional fine diamond inlay burs (model number
rial during sudden movements.17 AE signals, which usu- 011, Cerinlay; Intensiv, Grancia, Switzerland) with
ally have broadband characteristics, can be collected by a high-speed handpiece (KaVo K9, handpiece type
sensors in the AE transducers with an amplifier during 950; KaVo, Biberach, Germany) utilizing water spray.
the loading event.16 In a composite material, AE is A new set of burs was used after every 7 preparations.
highly sensitive and does not only detect crack growth Boxes, on the distal surface of 7 premolars and the mesial
and material deformation but also solidification, fric- surface of 7 molars, with margins in enamel, at least 1
tion, impact, flow, phase transformations, and the stress mm above the cemento-enamel junction, were prepared
released when matrix crazing, fiber breakage, debond- by the first operator. The second operator prepared the
ing, or any other microstructural failure occurs.17 boxes first, using conventional fine diamond inlay burs
Advantages of using the AE method to test and analyze (model number 011, Cerinlay; Intensiv) followed by
FRC include the ability to obtain real time data and the small or large ultrasonic tips (SONICSYS approx, micro
method’s high sensitivity to a process or mechanism torpedo; KaVo) for the premolars and the molars, re-
within a composite material that generates AE spectively (Fig. 1, A). The linear oscillation speed was
signals.18,19 6.5 kHz. Subsequently, the dimensions of the boxes
The strength of FRCs is often reported as the ulti- were measured at buccolingual (BL), mesiodistal
mate flexural strength of the final fracture.21,22 A (MD), and cervico-occlusal (CO) directions with a digi-
number of factors affect the strength of inlay-retained tal micrometer (accurate to 0.005 microns) (Mitutoyo
FPDs, one of which is the dimension of the prepara- Ltd, Andover, UK). The preparations were cleaned
tion.23-25 Recently, instruments based on oscillating with water spray and dried with an air syringe
Table I. Dimensions (mm 6 SD) of boxes in buccolingual (BL), mesiodistal (MD), and cervico-occlusal (CO) direction
prepared using conventional burs and ultrasonic tips for both molars and premolars
Molar Premolar
Cavity preparation systems BL* MDy COz BL§ MD|| CO{
Conventional inlay burs 3.1 (6 0.2) 4.3 (6 0.9) 3.8 (6 0.2) 2.8 (6 0.2) 2.9 (6 1.2) 3.0 (6 0.4)
SONICSYS approx tips (small) 2.9 (0) 3.8 (6 0.5) 3.6 (6 0.1) 2.5 (6 0.1) 2.7 (6 1.0) 2.9 (6 0.1)
SONICSYS approx tips (large) 3.2 (6 0.2) 4.9 (6 0.1) 3.9 (6 0.1) 2.6 (6 0.1) 3.8 (6 0.1) 3.6 (6 0.1)
Mean values of box dimensions in each group for initial and final failure were analyzed by 2-way repeated measures ANOVA, with direction as repeated-measure
factor and group as between-group factor. Further analyses were performed with 1-way ANOVA, the Bonferroni correction in multiple comparisons within each
direction for molar and premolar specimens (a=.05).
*Conventional vs small, P=.031; small vs large, P=.0023.
y
Small vs large, P=.007.
z
Conventional vs small, P=.028; small vs large, P=.0032.
§
Conventional vs small, P=.0024.
||
Small vs large, P=.021.
{
Conventional vs large, P=.0003; small vs large, P=.0001.
Table II. Results of 2-way repeated measures ANOVA for Table III. Results of 2-way repeated measures ANOVA for
molars premolars
Source of variation df SS MS F P Source of variation df SS MS F P
York, Pa). With 2 transducers, the source of AE was were performed with 1-way ANOVA (a=.05), using the
located in the test specimen and transducers using Bonferroni correction in multiple comparisons within
silicone-based lubricant (Silikonfett Wacker-Chemie, each direction for molar and premolar specimens. The
Munich, Germany). Signals detected by transducers difference between the fracture-strength values depen-
were passed through preamplifiers of 40 dB gain, dent on the preparation techniques evaluated was ana-
with a band pass of 10 kHz to 2 MHz (Model lyzed with 1-way ANOVA. Furthermore, the Fisher
2/4/6; Physical Acoustic Corp). AE signals were exact test was used to determine the statistical difference
recorded during the loading cycles with software in the type of failure between groups in which 3 prepa-
(MISTRAS 2001; Physical Acoustic Corp) using ration techniques were used (a=.05).
4-MHz sample frequencies. After each fracture test, the
failure type, veneering composite delamination, cata-
RESULTS
strophic failure, and combination of failure type and fail-
ure location were identified by visual examination, and Significant differences were observed between the
digital photographs were made from buccal, lingual, groups in the dimensions of the boxes prepared using
and occlusal aspects of the specimen (Nikon Coolpix conventional burs and the small or large size ultrasonic
990; Nikon, Tokyo, Japan). tips at the BL, MD, and CO directions for both the pre-
Statistical analysis was performed using statistical molars (2.8 mm, 2.9 mm, 3.0 mm) (P=.0029, P=.0014,
software (SAS, Windows 8.02; SAS Institute, Inc, P,.0001) and the molars (3.1 mm, 4.3 mm, 3.8 mm)
Cary, NC). The mean values of box dimensions in (P=.0024, P=.0086, P=.003), respectively (Tables I,
each group for initial and final failure were analyzed by II, and III).
2-way repeated-measures analysis of variance After thermal cycling, although there was a trend
(ANOVA), with direction (BL, MD, CO) as the re- towards increased fracture strength values in the
peated-measure factor and group as the between-group FPDs prepared with the larger size ultrasonic tips, no
factor. Because the interaction terms between the significant difference was identified for the initial and
groups and dimensions were significant, further analyses final failures between the conventionally prepared
Fig. 2. A, Acoustic emission rates showing some initial failures at lower energy levels between 50 and 75 (mV)2 that
corresponded to 400 N and 700 N before final failure in group prepared with conventional burs. B, Acoustic emission rates
showing peaks at energy levels at 250 (mV)2 that corresponded to 1100 N before final failure in group prepared with small
ultrasonic tips. C, Acoustic emission rates showing peaks at energy levels of 100-150 (mV)2 that corresponded to 500-800 N
before final failure in group prepared with large ultrasonic tips.
Fig. 2.—Cont’d.
group (842 6 267 N, 1161 6 428 N) and those pre- within the fiber itself occurred. The Fisher exact test
pared with either the small size (1088 6 381 N, 1320 demonstrated no significant difference between the fail-
6 380 N) or large size (1070 6 280 N, 1557 6 321 ure types (P=.3).
N) ultrasonic tip combinations. The AE tests revealed
that some initial failures occurred at lower energy levels
DISCUSSION
between 50 to 75 (mV)2, which corresponded to 400
N to 700 N before final failure in the FRC FPDs in Minimal or no tooth preparation of the abutment
the restorations for which boxes were prepared using teeth is desirable for the replacement of missing teeth
conventional inlay burs (Fig. 2, A). The energy level with FRC FPDs. However, depending on the clinical
required for fracture was 250 (mV)2, corresponding situation, especially in posterior applications, sufficient
to 1100 N in the restorations for which boxes were space is required for the fiber frame and the resin com-
prepared using small ultrasonic tips (Fig. 2, B), and posite materials. When space is insufficient, wear of the
100 to 150 (mV)2 at 500 N to 800 N when large composite may result in early failure of the restoration
ultrasonic tips were used (Fig. 2, C). or in fiber exposure that may lead to plaque accumula-
Table IV displays the number of fracture types of tion. In this study, ultrasonic tips were used in an
FRC FPDs per group relative to the different types of attempt to standardize substructure geometry. The
preparation. Three types of failure were observed: (1) dimensions of the box preparation demonstrated a
delamination of the veneering resin (VD) (18/21) ei- wide range (1.8 to 5.2 mm) in the BL direction with
ther at the lingual and buccal surface with a crack path the use of conventional inlay burs when compared to
in the mesiodistal direction, (2) catastrophic failure the dimensions of the boxes prepared under controlled
(CF) (1/22), in which fracture was at the connector circumstances using the ultrasonic tips (Table I).
area with some fiber exposure, or (3) a combination of However, although there was a trend toward higher
both (VD1CF) (2/21). Delamination of the veneering strength values in the boxes prepared with the large
resin was the predominant failure. The only CF, includ- ultrasonic burs, no significant difference was found at
ing the fracture at the connector area, was noted for the initial and final failure compared to the group prepared
group in which boxes were prepared with the traditional using conventional inlay burs. There were no failures
burs. The 2 specimens with combined failure were pre- at the connector area with the use of either small or large
pared using large ultrasonic burs (Fig. 3). No fracture tips; however, with such a small sample size, it is difficult
Resin composites with different elastic moduli could were needed to obtain a power of 80% in detecting
affect the initial and final failures. The flexure strength of differences between group mean values. Clinically,
fiber-reinforced restorations might be improved with factors such as span length, pointed cusps, cusp
the use of new polymer formulations with high filler- height, anatomical variables of the antagonist teeth,
particle distribution (Estenia, Sinfony, Gradia, shock absorbance characteristics of the periodontal
Sculpture) that are now commercially available; how- ligament, and direction of the masticatory forces
ever, these materials are not suitable for chairside use.5 may cause slight deviations in force transfer, resulting
The changes in energy levels revealed small failures in different tension areas in FRC FPDs that require
occurring between 300 N to 500 N and continuing until further investigation.
final failure occurred. While no fractures were observed
at the connector area, the failure analysis demonstrated CONCLUSIONS
that the weakest parts of the restoration were in the
Within the limitations of this in vitro study, the
cohesive strength of the veneering composite and the
following conclusions were drawn:
bond between the fiber composite framework. The di-
rection of the failures was primarily in the MD direction, 1. The box dimensions prepared with conventional
indicating that unidirectional fibers change the path of burs varied significantly (P=.0146 and P=.0086 for the
the crack. premolars and molars, respectively) compared to those
Clinically, when using FRC for FPDs, an important prepared under controlled conditions using ultrasonic
parameter may be the initial failure point. Some studies tips.
have determined the fracture forces of FPDs by deter- 2. Standardized box dimensions had no significant
mining the initial failure from the force deflection effect on fracture strength at either initial or final failure
curve.11,13 A more precise method for determining the of the FRC FPDs.
initial failure point is based on determining the initiation 3. According to the AE tests, a higher energy level
of AE signals.17 When comparing the relationship be- was required for the final failure of the FRC FPDs
tween the stress for the first AE activity observed at ini- with boxes finished using small ultrasonic tips.
tial failure and the strength needed for the final failure, 4. The predominant failure type after the fracture
AE started at a lower stress level in specimens for which test was delamination of the veneering resin.
the boxes were prepared using conventional inlay burs
and large ultrasonic tips. However, more energy was re-
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