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Clinical Implications
Plotino et al
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tive.1 Such materials not only seal the
margin,2 but several studies have also
shown that the use of adhesive materials can reduce the weakening effect
of preparation designs.3,4 In fact, cavity preparation procedures for dental
restorations are a primary factor in
most cuspal fractures,5 especially for
endodontically treated teeth.6,7 Adhesive resin-based restorative techniques for posterior endodontically
treated teeth can be either in the form
of direct composite resin restorations
or composite resin inlays/onlays.
Each of these restorative procedures
has unique advantages and disadvantages. The preferred technique is not
obvious, considering that the clinical
wear of composite resin inlays is expected to equal the wear resistance of
direct posterior composite resin restorations.8 There is also no scientific
evidence to support manufacturers
claims that extraoral postpolymerization improves the wear characteristics
and the mechanical properties of the
material.9,10
Recently developed composite resins are superior to previous versions
with regard to wear resistance and color stability.11,12 However, the primary
shortcoming of composite resins,
polymerization shrinkage, remains a
concern.13 In posterior preparations,
especially when the cervical margin is
located in dentin, the polymerization
shrinkage effects can be significant,
producing marginal defects and gaps
despite careful application.14 This result facilitates microleakage, which
could promote secondary caries,
marginal discoloration, and, in vital
teeth, pulpal irritation and postoperative sensitivity.15 To minimize the
development of stresses, it is important to use incremental placement
techniques, in which the composite
resin is applied in thin or oblique layers and then polymerized throughout
the cusps.16 The composite resin inlay systems were introduced for large
defects, with the aim of overcoming
some of the problems associated with
directly placed posterior composite
resin restorations, such as the polym-
Plotino et al
227
March 2008
assessed with 1-way analysis of variance (ANOVA) to determine significant differences between groups. The
control group contained teeth that remained intact; the teeth of the other
2 groups were subjected to the endodontic and restorative procedures.
Two preliminary radiographs were
made in bucco-lingual and mesio-distal directions to determine root canal
anatomy. Endodontic treatment was
performed using NiTi rotary instruments (ProTaper; Dentsply Maillefer,
Ballaigues, Switzerland). Five percent
sodium hypochlorite was used for irrigation during the endodontic treatment. A 17% EDTA solution (EDTA
17%; OGNA Laboratori Farmaceutici,
Milan, Italy) was used after the last
instrument, followed by a final flush
with saline solution. The canals were
dried with paper points (Dentsply
Maillefer) and all roots were obturated with laterally condensed guttapercha (Dentsply Maillefer) and resinbased endodontic sealer (Topseal;
Dentsply Maillefer). The access opening was sealed with an elastic lightpolymerizing provisional restorative
material (Fermit; Ivoclar Vivadent,
Schaan, Liechtenstein) to protect the
endodontic filling material from leakage of the saline storage media. The
teeth were then stored in buffered saline plus 0.5% thymol at 37C for 1
week to ensure complete polymerization of the sealer.
One operator made all of the
preparations and restorations. The
enamel and dentin of the access cavity were etched with 37% phosphoric
acid (3M ESPE, St. Paul, Minn) for 40
seconds and 20 seconds, respectively,
rinsed for 20 seconds with an air/water spray, and gently air-dried to avoid
dessication. The primer (Scotchbond
Multi-Purpose Primer; 3M ESPE) was
applied with a microbrush to the
tooth surface for 20 seconds and then
air-dried for 5 seconds. Light-polymerizing adhesive (Scotchbond MultiPurpose Adhesive; 3M ESPE) was
applied with another microbrush, the
excess was gently air-thinned, and the
surface was exposed to an LED-po-
Plotino et al
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Volume 99 Issue 3
the cavity preparation extended mesio-distally to include the distal occlusal fossa, thus preserving the distal
marginal ridge. The axial wall length
was 1.5 mm. The angles of divergence
of the preparation walls were approximately 5-15 degrees, and the internal
line angles were rounded. Occlusal
finish lines were not bevelled.
Clinical and laboratory procedures were standardized as follows.
Fifteen teeth were restored with direct
composite resin restorations (DIR).
Immediately following that, the foundation was placed and the cavity was
prepared. Fifteen teeth were restored
with indirect composite resin restorations (IND); a week later, the foundation was placed and the cavity was
prepared.
For teeth restored with direct composite resin restorations (DIR), adhesive procedures of the preparation
(enamel, dentin, and foundation)
were repeated as described above.
A matrix retainer system (Tofflemire
matrix; Miltex Inc, York, Pa) was used
and changed for each restoration.
The matrix was tightened and held
by finger pressure against the gingival
margin of the cavity, so that the preparations could not be overfilled at the
gingival margin. The composite resin
(Estelite Sigma; Tokuyama Dental
Corp, Tokyo, Japan) was placed using
the oblique incremental technique,42,43
and each increment was no more than
1.5 mm to ensure adequate polymerization. Each increment was polymerized for 40 seconds (20 seconds of
slow-rise function repeated 2 times)
with an LED-polymerizing unit with
a power light intensity of 800 mW/
cm2 (Starlight pro; Mectron SpA) in
contact with the occlusal surface of
the tooth. The external layer was polymerized after placement of a glycerine gel (DeOx; Ultradent Products
Inc, South Jordan, Utah) to maintain
an anaerobic environment to permit
complete polymerization of the resin
surface. The composite resin restorations were formed with A3 shade in
order to simulate dentin, and a final
thin layer of 0.5-1 mm of A1 shade to
simulate enamel.
The matrix was removed, and to
ensure that the deepest parts of the
interproximal box had been polymerized adequately, each restoration was
further polymerized for 60 seconds
from the buccal aspect and 60 seconds from the lingual aspect of the
box. After polymerization, specimens
were finished and polished with rubber cups and points (Identoflex; KerrHawe SA, Bioggio, Switzerland).
For prepared teeth to be restored
with indirect composite resin restorations (IND), impressions with a
vinyl polysiloxane (Aquasil; Dentsply
Caulk, Milford, Del) were made using
a custom-made impression tray. The
impressions were poured with a vacuum-mixed type IV stone (FujiRock EP;
GC Italia Srl, San Giuliano Milanese,
Italy) and separated from the dies after 1 hour. After separation, the cast
was carefully evaluated to ensure that
the finish line was entirely visible, and
that there were no distortions, air
bubbles, or undercuts, prior to sending the cast to the dental laboratory.
The dies were coated with separating medium (Tenatex wax; Kemdent,
Swindon, UK) and onlays were fabricated with the same composite resin
and technique used for the direct restorations. Onlays were further polymerized in a light-heat polymerization
oven (LaborluxL 300W; Micerium
SpA, Avegno, Italy) for 10 minutes.
Each restoration was verified for
fit accuracy and adjusted accordingly,
then finished with a fine diamond rotary cutting instrument (Intensiv FG;
Intensiv). Both the internal surfaces
of the onlays and the teeth were airborne-particle abraded with 50-m
silica-coated aluminium-oxide particles (Special sand, Kumapan; Consorzio Onda, Grugliasco, Italy). Then
the teeth were treated, as previously
described for the DIR specimens, with
etching, primer, and bonding agents.
The onlays, after the airborne-particle
abrasion, were cleaned with ethyl alcohol (95% vol), and silane and bonding
agents were applied. The same dualpolymerizing composite resin (Virage
Plotino et al
229
March 2008
choice of this angulation was based
on anatomic observation.46 Continuous compressive force at a crosshead speed of 1.6 mm/s was applied
in a universal load testing machine
(LR30K; Lloyd Instruments Ltd, Fareham, UK) using a 6-mm-diameter steel
ball (Fig. 3). The fracture loads were
determined in Newtons (N), and the
modes of fracture were recorded and
classified by 2 independent observers
using a stereomicroscope (Stemi SV6;
Carl Zeiss SpA). Favorable failures
were defined as repairable failures,
including adhesive failures, above the
level of bone simulation. Unfavorable
failures were defined as nonrepairable
failures, including (vertical) root fractures, below the level of bone simulation.47 Disagreements were resolved
by discussion between the 2 observers.
The data were analyzed using statistical software (SPSS 11.0; SPSS Inc,
Chicago, Ill). Data were subjected to
a Kruskal-Wallis test to determine
significant differences in failure loads
among groups. When the KruskalWallis test indicated a significant difference, multiple comparisons were
performed using the Mann-Whitney
test to determine which group differed
from the others. Percentages were determined for the mode of failure, and
statistical evaluation was completed
using a chi-square test to determine
significant differences in the mode of
failure among groups. A preset alpha
level of .05 was used for all statistical
analyses.
RESULTS
Mean (SD) bucco-lingual and mesio-distal dimensions of the teeth were
9.94 (0.46) mm and 11.25 (0.50) mm
for DIR specimens, 9.86 (0.42) and
11.12 (0.54) mm for IND specimens,
and 9.97 (0.50) and 11.30 (0.53) mm
for control specimens, respectively.
The mean sizes of the teeth in the 3
groups were not significantly different
for bucco-lingual (P=.797) or mesiodistal (P=.627) dimensions.
The Kruskal-Wallis test showed
Plotino et al
Favorable
Unfavorable
DIR (direct)
33% (n = 5)
67% (n = 10)
IND (indirect)
33% (n = 5)
67% (n = 10)
Intact teeth
40% (n = 6)
60% (n = 9)
DISCUSSION
The results of the present study
support the null hypothesis that there
is no difference in the resistance to
fracture and the mode of failure between direct and indirect composite
resin restorations in endodontically
treated molars prepared with an extensive loss of tooth structure.
Numerous studies have been conducted to determine the ideal method to restore endodontically treated
teeth. Endodontic treatment is considered to weaken teeth, resulting in
increased susceptibility to fracture.
Consequently, authors suggest that
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Volume 99 Issue 3
cuspal coverage with cast restorations
is necessary for predictable restorative success of endodontically treated
posterior teeth.7
It has been shown that the resulting weakening of teeth due to restorative procedures increases with
the reduction of tooth structure.25-27
According to Reeh et al,6 endodontic
procedures have only a small effect on
the tooth, reducing the relative rigidity by 5%, which is contributed entirely by the access opening. Restorative
procedures and, particularly, the loss
of marginal ridge integrity, were the
greatest contributors to loss of tooth
rigidity. The loss of 1 marginal ridge
resulted in a 46% loss in tooth rigidity, and an MOD preparation resulted
in an average loss of 63% in relative
cuspal rigidity.
Metal onlays and crowns have
traditionally been recommended for
large restorations, including cusp
coverage. More recently, the use of
indirect composite resin techniques
has been indicated as well.34,35 However, biomechanically, there is no evidence that indirect composite resin
restorations are superior to direct
restorations, and there are few longitudinal studies on the clinical behavior of extensive composite resin
restorations.33,36-39 Complex direct
composite resin restorations exhibit
durability and have been shown to
have sufficient strength to withstand
occlusal forces and protect the remaining tooth structure.8,33 Clinical
evidence suggests that the longevity
of direct composite resin posterior
restorations is equal to that of indirect composite resin posterior restorations.11 Nevertheless, there is sparse
long-term information concerning the
longevity of cusp-replacing composite
resin restorations.33
The results of the present study
demonstrated that there are no differences in the in vitro fracture resistance of extensive direct and indirect
composite resin restorations. These
results are in agreement with those
of Kuijs et al,51 who reported no differences in fracture strength between
Plotino et al
231
March 2008
CONCLUSIONS
Within the limitations of this in
vitro study, endodontically treated
molars prepared with an extensive
loss of tooth structure and restored
to their original contours with direct
composite resin restorations presented a resistance to fracture under simulated occlusal load not significantly
different than that of indirect composite resin restorations. Restored
teeth had a decrease in fracture resistance compared to intact teeth. Furthermore, no differences were found
in the mode of failure of the restored
and intact teeth.
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49.Dalpino PH, Francischone CE, Ishikiriama
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Corresponding author:
Dr Gianluca Plotino
Via Eleonora Duse, 22
00197 Rome
ITALY
Fax: +39068072289
E-mail: gplotino@fastwebnet.it
Copyright 2008 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Plotino et al