Journal of Dentistry 147 (2024) 105106

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

The effect of ferrule and core material on fracture resistance of

endodontically treated anterior teeth restored with ceramic crowns after
artificial aging
Zakereyya S.M. Albashaireh *, Yasmeena K. Sbeih
Department of Conservative Dentistry, Jordan University of Science and Technology, P.O. BOX 3030, Irbid 22110, Jordan

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

Keywords: Objectives: To assess the influence of ferrule and core type on the fracture strength of endodontically treated
Fracture resistance anterior teeth (ETAT) and identify the failure mode type and distribution across different core types and ferrule
Composite cores conditions.
Posts
Methods: Sixty extracted human central incisors were endodontically treated, decoronated and divided into two
Ferrule
Artificial aging
main groups (F=with ferrule, NF=no ferrule). Each main group was further subdivided into three subgroups
Ribbond fibres according to the core material used: direct composite cores (DC), Ribbond fibre-reinforced composite cores (RIB-
DC), and glass fibre post (GFP) with direct composite cores (GFP-DC). All specimens received E.max crowns and
underwent thermal cycling and cyclic loading. Subsequently, the fracture resistance was tested with static loads
applied to the crown restoration. Two-Way ANOVA and Chi square tests identified significant differences among
the groups (p < 0.05).
Results: The means and standard deviations (SD) of fracture loads in Newtons (N) for specimens in the F sub­
groups were RIB-DC: 465.0 (104.20), GFP-DC: 367.6 (79.59), DC: 275.8 (68.48), and in NF subgroups were RIB-
DC: 110.8 (24.33), GFP-DC: 95.6 (25.47), DC: 67.4 (7.46). Specimens with ferrule yielded significantly higher
fracture loads than those without ferrule (p = 0.0054). In the F groups, fracture loads of specimens with RIB-DC
cores were significantly higher than those with GFP-DC (p = 0.0019) and those with DC (p = 0.0001). Moreover,
fracture loads for the GFP-DC were significantly higher than those for the DC (p = 0.0026). The GFP-DC spec­
imens showed the highest incidence of catastrophic failures (p = 0.0420).
Conclusions: Using fibre-reinforced composite (FRC) cores significantly increased fracture resistance in ETAT with
ferrule. The failure modes repairable and possibly repairable were dominant in most specimens.
Clinical significance: When restoring ETAT with insufficient coronal tooth structure, preserving 2 mm of tooth
structure ferrule and preparing cores with FRC can increase fracture resistance and reduce the incidence of non-
repairable catastrophic fractures of teeth.

1. Introduction Glass fibre posts have been increasingly used to retain adhesive cores
in the treatment of ETAT with insufficient coronal tooth structure,
Restoring ETAT with insufficient coronal tooth structure presents providing support for full coverage crowns [2]. The elastic modulus of
significant challenges for dental clinicians. Structural loss resulting from GFPs permits the distribution of loads more evenly and reduces the
caries, fractures, and endodontic therapy complicates the restoration probability of root fracture [3,4]. However, post space preparation
process. Major changes in the mechanical properties of endodontically weakens teeth, and poses risks of root fracture [5] and heat trauma to
treated teeth (ETT) are primarily attributed to the amount of dentine periodontal tissues [6]. Notably, superior survival of teeth with rigid or
loss, whereas changes in moisture and hardness after endodontic treat­ flexible post materials has not been conclusively demonstrated [7].
ment have a minimal impact [1]. Advances in dental adhesives and FRC technology have enabled

This work was supported by the Deanship of Research at Jordan University of Science and Technology, P.O. BOX 3030, Irbid 22110, Jordan [Grant number 2022/
0111].
* Corresponding author.
E-mail address: [email protected] (Z.S.M. Albashaireh).

https://doi.org/10.1016/j.jdent.2024.105106
Received 30 April 2024; Received in revised form 28 May 2024; Accepted 31 May 2024
Available online 1 June 2024
0300-5712/© 2024 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Z.S.M. Albashaireh and Y.K. Sbeih Journal of Dentistry 147 (2024) 105106

clinicians to restore ETAT without involving posts [8]. Teeth with 2. Materials and methods
traditional composite materials core buildups have been prone to sec­
ondary caries and composite bulk fractures [9,10]. These composite 2.1. Approvals, teeth collections, and sample calculations
bulk fractures have been attributed to their lack of ideal toughness
needed to prevent crack propagation [11–13]. This laboratory study was approved by the research committee under
Ribbond fibres, a type of dental reinforcement ribbon, have been the authorization number 711-2021. Teeth were collected from different
introduced to strengthen dental composites and enhance their me­ private and public dental clinics. The age range of teeth donors was
chanical properties [14]. Ribbond is a translucent leno weave composed 25–60 years. Sixty extracted caries-free and visually assessed fracture-
of flexible polyethylene fibres with ultra-high elastic modulus [15]. free, human maxillary central incisors with approximately similar di­
Ribbond fibres are highly bondable to dental composites due to cold gas mensions were selected, cleaned of calculus deposits, debrided of soft
plasma treatment [16] which enables complete incorporation of resin tissues, and stored in a 0.1% thymol solution (Caelo, Hilden, Germany)
into fibres, eliminating voids and making Ribbond a strong integral part at room temperature.
of the of the FRC restorations [17]. The lock-stitch feature of Ribbond’s Based on a previous study [35] a convenient sample size was
leno weave allows effective spread of forces in the fibres meshwork calculated by using a freely available statistical program software
without propagating the force stresses into the resin [18]. Ribbond fibres (G-Power*, Ver. 3.1.9.6, Düsseldorf in Germany) depending on the
act as a stress-absorbing layer within composite restorations [19], following criteria: an effect size of 0.45, significant P-value of ≤ 0.05 at 1
enhancing their mechanical properties [20] and significantly improving degree of freedom, a power (1-β) of 0.9. An effect size of 0.45 is
their fracture resistance [14,21,22]. considered moderate. It is neither too small that may not produce
The presence of ferrule, an axial circumferential collar of dentine meaningful results nor too large which makes the investigation
located above the finish line of crown preparation, plays a significant impractical and unrealistic. Thus, it keeps the sample size manageable.
role in the success of the restorative treatment of ETAT [23]. The ferrule With these calculations, a minimum sample size of 54 specimens was
contributes to the overall strength and retention of the restoration. By determined. An additional 10% was added to the calculated sample size
evenly distributing chewing forces on the restoration, it helps lower the resulting in a final sample size of 60 specimens, with 10 specimens
risk of fracture [24]. Additionally, the ferrule provides a solid founda­ allocated to each subgroup.
tion and stability [25] allowing for a proper marginal seal which is
essential for preventing microleakage and recurrent caries [26]. The 2.2. Experimental groups and subgroups
ferrule effect is influenced by several parameters, including its height,
thickness, and completeness. Ideally, a ferrule height of at least 1.5 to 2 Teeth were allocated equally into two main groups according to the
mm is recommended to enhance fracture resistance and overall stability presence (F) or absence of ferrule preparation (NF). Teeth in each main
of the restoration [27]. The thickness of the ferrule, typically 1 mm or group (N = 30) were then evenly distributed into three subgroups (N =
more, contributes to the distribution of functional stresses, reducing the 10) based on the core material used: direct composite cores (DC), Rib­
risk of tooth fracture [28]. Furthermore, a complete all-around ferrule, bond fibre reinforced composite cores (RIB-DC), and GFP and composite
which encompasses the entire circumference of the tooth, provides su­ cores (GFP-DC). Details of experimental groups and subgroups are pre­
perior reinforcement compared to an incomplete ferrule [23,29]. sented in a CONSORT flow diagram (Fig. 1).
However, a recent systematic review and meta-analysis has ques­ Isomet high concentration diamond sectioning disc (Isomet, Buehler;
tioned the significance of ferrule effect in reducing the failure rate in Lake Bluff, IL) was used for crown decoronation under water cooling. In
teeth restored with fibre posts [26]. Conversely, several in vitro studies the (F) group, the crowns were sectioned 2 mm above the level of the
have demonstrated that the absence of ferrule could not be compensated labial CEJ, while in the (NF) group, the sectioning was at the level of the
by using cores on GFP, or other core buildup materials [27,30,31]. labial CEJ. A standard circumferential ferrule, 2 mm in length and 1 mm
The success of restorative treatment for ETAT depends on the sur­ in thickness, was prepared before building the cores for teeth allowing 2
vival rates of the crown restorations and tooth restorability after failure mm long and 1 mm thick axial dentine wall.
ETAT of previous restoration [8]. Using FRC cores in conjunction with E.
max crowns to restore ETAT with insufficient coronal tooth structure 2.3. Endodontic treatment procedures
may prove successful. Indeed, FRC have been reported to effectively
prevent unrepairable catastrophic failures, thereby enhancing the The pulpal tissues in all root canals were removed with a barbed
overall success of restorations [32–34]. broach of an appropriate size. Then, a size15 K-file was introduced in the
root canal until it was visible at the apical foramen. The file length was
1.1. Objectives and null hypotheses measured from the reference point at the cut surface to the apical end,
and the working length was determined by subtracting 1 mm from that
The purposes of this study are to: length. A periapical radiograph was taken with digital sensor (VistaRay
7 Sensor, Durr Dental, Germany) to confirm the working length. Sub­
Evaluate the effect of different core types on the fracture resistance of sequently, the canals were prepared with a rotary system (ProTaper
ETAT with or without a ferrule. Gold Rotary File System, Dentsply Sirona, Charlotte, NC, US) driven by
Assess the influence of ferrule presence on the fracture resistance of endodontic micromotor (X-smart, Dentsply, Ref A 1004, Switzerland)
teeth restored with different core types. until F3 file. Canals were irrigated with 5.25% sodium hypochlorite
Identify the failure modes and their distribution according to core solution (PD, Dentaires, Switzerland) and rinsed with 17% EDTA solu­
type and ferrule presence. tion (i-EDTA solution, i-dental, Lithuania) for 1 min followed by sodium
hypochlorite (Dentaires, Switzerland) for 1 min and finally with 0.9%
The null hypotheses were: (I) There is no significant difference in normal saline. Root canals were then dried with matching F3 paper
fracture resistance among teeth restored with different core types; (II) points (ProTaper Gold, Absorbent Points, Dentsply Sirona). Eugenol-free
The presence of a ferrule does not significantly affect the fracture epoxy amine resin sealer (AH Plus sealer; Dentsply DeTrey, Konstanz,
resistance of teeth restored with different core types; and (III) There is no Germany) was placed circumferentially within the canals till working
significant difference in the distribution of failure modes among teeth length with a size 10K-file (M-access K-flexofile, Dentsply Maillefer,
restored with different core types and ferrule presence conditions. Switzerland). Then F3 gutta-percha cone (ProTaper Gold Conform fit
Gutta Percha Points, Dentsply Sirona) was inserted 0.5 short of the
working length ensuring a strong tug back was felt. Canal obturation

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Z.S.M. Albashaireh and Y.K. Sbeih Journal of Dentistry 147 (2024) 105106

Fig. 1. Consort graph illustrating the experimental groups.

was completed with warm vertical compaction technique by using

Table 1
Woodpecker obturation system (Woodpecker Fi P, China). A periapical
Composition and lot number of core materials and luting resin cement.
radiograph was taken with digital sensor (VistaRay 7 Sensor, Durr
Dental) to confirm optimal obturation. Finally canal orifices and root Material Composition Lot
number
apices were sealed with modelling wax and teeth were stored in distilled
water at room temperature for 72 h. SE Bond Primer: 10-MDP, 2-HEMA, hydrophilic aliphatic 8R0387
dimethacrylate, butylated hydroxytoluene, dl- 910740
Camphorquinone, water, accelerators, dye.
Bond: 10- MDP, Bis-GMA, 2-HEMA, diphenyl (2,4,6-
2.4. Restorative procedures trimethyl benzoyl) phosphine oxide, hydrophobic
aliphatic dimethacrylate, amorphous silica, accelerator,
The cores were built up by a single operator by using a consistent dl-Camphorquinone.
Clearfil Bis-GMA, triethylene glycol dimethacrylate, silanated 910124
method. The gutta-percha was trimmed 3 mm below the canal orifice
AP-X barium glass, silanated silica, silanated colloidal silica,
level. In the F group, composite cores were constructed to a thickness of dl-Camphorquinone.
7 mm thick to accommodate the 2 mm ferrule preparation, resulting in a Ribbond Ultra-high molecular weight polyethylene. 27246
total core thickness of approximately 9 mm. While in the NF group, Panavia Bis-GMA, TEGDMA, titanium dioxide, silanated barium 4E0086
composite cores were prepared to a thickness of 9 mm to compensate for V5 glass filler, hydrophobic aromatic dimethacrylate,
hydrophilic aliphatic dimethacrylate, silanated
the absence of the 2 mm thick ferrule. All cores were then prepared to
fluoroaluminosilicate glass filler, silanated alumina
achieve shoulder finish lines of 1 mm to receive E.max full crowns. filler, dl-Camphorquinone, accelerators, initiator,
pigments.
2.4.1. DC cores
The bond primer (Clearfil SE, Kurary Noritake, Japan) was applied
and rubbed on the entire preparation surfaces for 20 s and gently air were coated abundantly with the bond (Clearfil SE Bond, Kurary Nor­
itake, Japan), then excess resin was removed by moving the wetted
dried. Subsequently, the bond (Clearfil SE Bond, Kurary Noritake,
Japan) was applied, and a gentle air stream was blown on the bond to Ribbond on a dry mixing pad and then dabbing a finger gently against it.
Subsequently, a 1 mm thick layer of flowable composite (Clearfil AP-X
make a uniform thickness. The bond was polymerized with a light-
polymerizing unit (D-Light Pro, GC Dental, Europe) with a continuous Flow, Kuraray Noritake, Japan) was applied inside canal orifice and
left unpolymerized. The wetted Ribbond pieces were then positioned
output of 700 mW/cm2 for 20 s. A layer of flowable composite resin
(Clearfil AP-X Flow, Kurary Noritake, Japan) was applied to seal gutta- parallel to each other in the flowable composite, one against the palatal
wall and the other against the buccal wall of the cervical portion of the
percha and was light polymerized for 20 s. Subsequently, the composite
core build-up was conducted by using 2 mm thick increments of pack­ canal and this assembly was light polymerized for 20 s. Composite core
buildup proceeded by using the packable composite (Clearfil AP-X,
able composite material (Clearfil AP-X, Kurary Noritake, Japan) until
the desired composite thickness was achieved. The lot numbers, Kurary Noritake) in 2 mm increments until the desired composite
thickness was achieved.
composition details of materials used for core build up are presented in
Table 1.
2.4.3. GFP-DC cores
2.4.2. RIB-DC cores Gates Glidden burs of appropriate sizes were used to remove 10 mm
of gutta-percha from the root canals in the F group and 8 mm in the NF
Two Ribbond ribbons (Ribbond THM, Ribbond, Seattle, US), 9 mm
long, 0.18 mm thick and 2 mm wide were cut with special scissors group. Then, the post space was prepared with a size 2 post drill (3M
(Ribbond Scissors, USA, Seattle) and used for each tooth. Ribbond pieces RelyX Fiber Post Drill, 3M ESPE, Germany) matching the diameter of a

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Z.S.M. Albashaireh and Y.K. Sbeih Journal of Dentistry 147 (2024) 105106

size 2 GFP post (RelyX fiber post 3D, 3M ESPE, Germany) that fits the Jinan Testing Equipment IE Corporation, China) was used to apply an
space preparation. Post surfaces were air-borne-particle abraded with increasing load at a crosshead speed of 2 mm/minute below the incisal
50-mm alumina particles for 5 s by using a microblaster (Microjato edge of the palatal surface at 45◦ angle to the vertical. Failure loads in
Microblaster, Bio-art, Brazil) installed on a dental unit. Self-adhesive (N) were determined when a sudden decrease in the applied force
resin cement (RelyX U200, 3M ESPE, Germany) was used to cement occurred representing the maximum force required to cause fracture in
GFP in the prepared post spaces according to manufacturer’s in­ the specimen.
structions. The cement was light polymerized for 40 s. Subsequently DC
cores were constructed by applying the technique used for specimens in 2.9. Failure modes assessment
other subgroups.
Fractured specimens were examined under a digital microscope
2.5. E.max crowns fabrication (Leica M420; Leica Microsystems, Wetzlar, Germany) at x8 to determine
the failure modes. These failures were categorized into 3 distinct cate­
A maxillary left central plastic incisor (Nissin Dental Products, Kyoto, gories based on the potential of tested teeth restorability as follows:
Japan) served as a model for artificial crown fabrication. It was scanned Mode repairable: comprised repairable failures that involved no root
with a laboratory scanner (Medit T500, Medit Crop, Seongbuk District, fractures but included fractures or chipping of the E.max crowns alone,
South Korea) and a digital model replica was obtained. All subsequent E. adhesive failure between the resin cement and composite cores or be­
max crowns were fabricated to exact generic copies of the digital model. tween composite core and tooth structure, and cohesive failure of
The crown preparations of natural teeth were scanned with the same composite cores (Fig 2A). Mode possibly repairable: included poten­
laboratory scanner. Afterward, computer-aided design (CAD) software tially repairable failures that involved root surface fracture extending
(exocad, Darmstadt, Germany) was used to design E.max crowns by less than 2 mm below CEJ (Fig. 2B). Mode catastrophic: encompassed
copying the exterior coronal dimensions and anatomical features of the catastrophic failures that involved fracture of the root surface extending
digital model. All fabricated crowns were 11 mm long from the CEJ to more than 2 mm below the CEJ (Fig. 2C).
incisal edge. The cement space was accommodated by 0.05 mm spacer.
E.max blocks of BL1 shade (IPS E.max CAD, Ivoclar Vivadent, Schann, 2.10. Statistical analysis
Liechtenstein) were wet milled in the 5-axis milling machine (Ceramill
Motion2, Amann Girrbach AG, Koblach, Austria) and subjected to sin­ A two-way ANOVA test was performed to examine the effect of
tering process in which they were fully crystallized in the furnace ferrule, core material, and the interaction of the two factors on fracture
(Programat EP 5010 Ivoclar Vivadent, Schaan, Liechtenstein). The loads. Post-hoc comparisons were performed by using LSMEANS option
crowns were further refined and polished by using E.max polishing kit of the GLM procedure of SAS (SAS, OnDemand for Academics, 2015, SAS
(HP 360 Lithium Disilicate Polishing Kit, Eve Ernst Vetter, Germany). Institute, NC, US). The Chi-square test was used to compare failure
modes among the various groups. Statistical significance level was set at
2.6. E.max crowns cementation 0.05 for all tests.

The crowns were cemented with resin cement (Panavia V5, Kurary 3. Results
Noritake, Japan). The fitting surfaces were etched with 9.5% hydroflu­
oric acid (Porcelain Etch, Bisco, Schaumburg, US) for 20 s and rinsed Out of the initial 60 specimens that were included in the study, 6
thoroughly with water and dried. Then, the primer (Ceramic Primer Plus specimens (2 in F group, and 4 in NF group) failed during artificial aging
Kurary Noritake, Japan) was applied for 20 s and gently air dried. The and were considered as pre-test failures. Fracture loads for the fifty-four
tooth preparation was rubbed with a tooth primer (Tooth Primer Kur­ specimens that survived the artificial aging tests were recorded in N. The
aray, Noritake, Japan) for 20 s and then was gently dried. The resin means and SD for each subgroup are detailed in Table 2.
cement (Panavia V5, Kurary, Noritake, Japan) was dispensed directly Two-Way ANOVA test revealed significant effects of both ferrule and
onto the primed fitting surface of each crown and seated on the core core material type on the fracture resistance of the tested specimens (p <
preparation with thumb for 1 min. Excess cement was removed, and the 0.001). Additionally, the interaction between the factors ferrule pres­
cement was light-polymerized for 20 s on each surface. ence and core material was statistically significant (p = 0.0054), which
highlights further their combined influence on fracture resistance
2.7. Artificial aging (Table 3).
Post-hoc comparisons among the means demonstrated significantly
The roots of the crowned teeth were coated sequentially with 3 layers higher fracture loads for F subgroups compared to the NF subgroups (p =
of a silicone duplicating material (Elite double 22, Bisco, US) to create a 0.0054). Comparisons also revealed significant differences in mean
0.2 mm layer, replicating the periodontal ligament space, and extending fracture loads between F subgroups; and non-significant differences
2 mm short of the CEJ. Crowned teeth were then embedded into an auto- among NF subgroups (Table 2). In the F group, RIB-DC subgroup had
polymerizing epoxy resin (Epoxy Resin Jordan, Amman, Jordan) at 45◦ significantly higher mean fracture load than that of GFP-DC and DC
to the vertical and left to set fully for 72 h. Specimens were then stored in subgroups. Moreover, GFP-DC mean fracture load was significantly
distilled water at 37 ◦ C for 24 h before undergoing artificial aging. They higher than that of DC subgroup (Table 2).
underwent thermal cycling for 5000 cycles in distilled water, alternating The results of the chi-square test indicated a significant association
between temperatures of 5 ◦ C and 55 ◦ C in a thermal cycling machine between the core material used and the mode of failure (p = 0.042),
(Engineering Workshops Unit) following a previous protocol [36]. Af­ (Table 4). A higher proportion of repairable failures was noticed in the
terwards, specimens were placed in a dynamic machine, (Engineering DC and RIB-DC subgroups compared to the GFP-DC subgroup which had
Workshops Unit) and subjected to cyclic loading of 50N force at 1.6 Hz the highest number of specimens with catastrophic failures. Addition­
frequency for 1.2 million cycles simulating 5 years of clinical function ally, the presence of ferrule was associated with a significantly higher
[37]. Loads were applied at a 45◦ angle with the long axis of the palatal rate of catastrophic failures compared to more repairable failures in
surface of the crown targeting 2 mm below the incisal edge. teeth without ferrule (p = 0.006), (Table 5).

2.8. Fracture resistance testing 4. Discussion

For the fracture load test, a universal testing machine (WDW-20, This study evaluated the effect of different core types on the fracture

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Z.S.M. Albashaireh and Y.K. Sbeih Journal of Dentistry 147 (2024) 105106

Fig. 2. Photographs showing failed specimens with different failure categories as they appeared on the microscope. (a): Repairable failure involved cohesive failure
of the composite core (white arrows) it is noticeable that the ferrule was preserved (black arrow). (b): Possibly repairable failure involved root fracture that did not
extend more than 2 mm below the CEJ (white arrow). (c): Catastrophic failure involved fracture of the root with the fracture line extended more than 2 mm below the
CEJ (white arrow).

Table 2 Table 5
Mean fracture loads in N, and SD, of test subgroups. Number (N) and percentage (%) of specimens according to failure category and
Main groups Subgroups Fracture loads* SD
groups.
Groups Failure mode
F DC 275.8 c 68.48)
RIB-DC 465.0 a 104.20 Repairable Possibly repairable Catastrophic
GFP-DC 367.6 b 79.59
NF DC 67.4 d 7.46 N (%) N (%) N (%) p
RIB-DC 110.8 d 24.33 NF 14 (53.8) 11 (42.3) 1 (3.8)
GFP-DC 95.6 d 25.47 F 5 (17.9) 15 (53.6) 8 (28.6) 0.006
*Groups with means identified by different superscript letters are significantly
different, (P < 0.05).
* resistance, thereby the second hypothesis was rejected. Thirdly, the
Groups with means identified with the same superscript letters are not
significantly different (P > 0.05).
failure modes of ETAT varied significantly depending on the core ma­
terials used, consequently the third hypothesis was rejected.
Human maxillary central incisors were chosen for this study due to
Table 3 the inherent challenges associated with restoring anterior teeth [38].
Summary of 2-way ANOVA of main factors (core material and ferrule) and their The selected teeth were free of obvious craze lines and cracks that may
interaction for fracture resistance. potentially lower their fracture resistance. In clinical context, maxillary
Source of Sum of df Mean Square F P anterior teeth are subjected predominantly to non-axial loads, leading to
Variation Squares the generation of tensile stresses, and an increased risk of mechanical
Core Material 118,529.043 2 59,264.521 14.96 <0.0001 failures especially when restored with artificial crowns. In contrast,
Ferrule 1,028,612.176 1 1,028,612.176 259.7 <0.0001 posterior teeth typically experience compressive forces which are less
Material*Ferrule 46,294.887 2 23,147.444 5.84 0.0054 destructive in nature [38].
Error 190,113.597 48 3960.7 The present experiment was designed to test the fracture resistance
Total 1,383,549.704 53
of Ribbond-reinforced composite cores, which have potential clinical
applications. This was compared to fracture resistance of cores made of
DC and DC built on a GFPs, which are commoner in clinical practice. To
Table 4 study the effect of ferrule on fracture resistance, two groups of speci­
Number (N) and percentage (%) of specimens according to failure category and mens were utilized: one with a ferrule and another without. A standard
subgroups.
ferrule measuring 2 mm in height and 1 mm in thickness was prepared
Subgroups Failure mode P before the core buildup, consistent with previous reports to ensure
Repairable Possibly repairable Catastrophic uniformity among specimens in the ferrule group [27–29].
N (%) N (%) N (%)
In this study, all procedural preparations and core buildups were
carried out adhering to manufacturer guidelines. A light silicone
DC 6 (33.3) 10 (55.6) 2 (11.1)
duplicating material was used as a periodontal ligament (PDL)
RIB-DC 8 (47.1) 9 (52.9) 0 (0)
GFP-DC 5 (26.3) 7 (36.8) 7 (36.8) 0.042 replacement. This material was reported to have a modulus of elasticity
close to that of PDL fibres [39], thereby enhancing the relevance of the
findings to clinical conditions. The presence of a material that mimics
resistance and failure modes of ETAT prepared with and without a PDL space has been reported to have a significant effect on fracture
ferrule. The results partially rejected the first hypothesis and fully modes when performing fracture resistance tests [39]. Furthermore,
rejected the second and third hypotheses. Firstly, using FRC significantly teeth were embedded in epoxy resin because it has a modulus of elas­
improved the fracture resistance of ETAT, but this improvement was ticity close to that of alveolar bone, allowing it to transfer stresses in a
only observed in specimens with ferrule preparations. Secondly, the manner similar to bone [39]. This methodological approach, which in­
presence of a ferrule was crucial and significantly increased fracture corporates materials that simulate both the PDL and alveolar bone, adds

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Z.S.M. Albashaireh and Y.K. Sbeih Journal of Dentistry 147 (2024) 105106

strength to the study by providing a more accurate representation of the materials effectively compensated for the absence of the ferrule effect,
biomechanical environment in the oral cavity, thereby enhancing the aligning with results of other reports [27,31]. Similarly, Carvalho et al.
relevance of the findings to clinical conditions. [30] investigated fibre-reinforced bulk-fill composite resin and found no
The dynamic and continuous changes occurring in the oral cavity significant improvement in fracture resistance of ETAT without a
expose crown restorations to repetitive mechanical, thermal, and ferrule. However, the fibre-reinforced bulk-fill composite core showed
chemical stresses [36]. To reasonably assess their behaviour, thermal superior fracture resistance compared to GFPs. Their findings are
cycling and mechanical loading simulations were performed on the directly consistent with the findings of the current study.
specimens in this study, representing the most advanced in vitro tech­ Overall, these current findings underscore the importance of the
nique available for evaluating teeth under precisely defined biome­ ferrule effect in enhancing the fracture resistance of restorations. While
chanical conditions [36,37]. The mechanical loading pattern simulated the type of core material plays a significant role, its effectiveness is
5 years of intraoral clinical function which is the minimum time for markedly enhanced by the presence of a ferrule. This interaction high­
restorations to show different behaviours [37,40]. lights that for optimal fracture resistance, both factors, the selection of a
The results of this study confirm that the ferrule effect significantly strong core material and the incorporation of a ferrule preparation, are
influences the fracture behaviour of crown restorations on ETAT. A essential in the restorative treatment of ETAT.
previous study reported that specimens with a ferrule produced signif­ The success of the restorative treatment of ETT depends on their
icantly higher fracture resistance compared to those without [23]. The restorability after failure of the old treatment. Thereby, failure modes of
findings of the current study provide additional evidence to the existing the specimens were classified and analysed accordingly. The Chi square
body of knowledge, further supporting the well-reported significance of test revealed a significant difference in the failure modes across various
the ferrule effect in improving the fracture resistance of ETAT. core materials. Most of the failure modes in the DC and RIB-DC speci­
The significant increase in fracture resistance observed in the Rib­ mens were in the repairable and possibly repairable categories. Inter­
bond reinforced composite core group is not surprising and is consistent estingly, none of the specimens in the RIB-DC subgroups demonstrated
with previous findings. This result can be attributed to the material’s catastrophic failure which is consistent with other studies indicating
inherent mechanical properties [21,22]. Ribbond fibres offer excep­ that Ribbond fibres can redirect stresses and establish a fail-safe zone
tional strength and toughness and can reinforce composite cores by their [11,33,34]. In contrast, most specimens that exhibited catastrophic
two significant structural features that may ultimately improve fracture failure were in the GFP-DC subgroups, confirming results reported in
resistance. First, the lock-stitch feature in the leno weave facilitates the previous investigations [27,30,31].
effective spread of forces within the fibre meshwork [18]. Second, the Future research could investigate the fracture resistance of teeth
woven pattern with alternating strands enhances the dispersion of in­ restored with metal posts compared to those restored with GFP posts,
ternal stresses within the composite bulk reducing crack initiation and using different core materials.
propagation [20]. The strong bond between Ribbond fibres and resin
improves the physical properties of composite, as the fibres become an 5. Study limitations
integral component for strengthening the restoration [20].
In the present investigation, two pieces of Ribbond were strategically Despite efforts made to simulate clinical conditions, the study was
positioned adjacent to the buccal and palatal walls of each canal. Fibre conducted in a controlled laboratory setting, which may not fully
orientation within composite restorations has been emphasized for its replicate the complex and dynamic environment of the oral cavity.
critical role in enhancing their strength [17]. Thus, by placing Ribbond While the periodontal ligament was simulated using elastic impres­
fibres on the side experiencing tension forces, the load-bearing capacity sion material around the roots, other aspects such as saliva, and mi­
of composite restorations can be significantly improved [17]. Similarly, crobial activity were not replicated.
the use of GFPs as a core foundation further enhances fracture resistance The study focused on specific core types (DC, RIB-DC, and GFP-DC),
compared to direct composite cores without posts. Moreover, GFPs, with and could not explore other materials and combinations, which could
an elastic modulus like dentine, contribute to a more uniform stress limit the generalizability of the current findings.
distribution within the restoration, thereby reducing the risk of root Overall, it is difficult to correlate the conditions applied in this study
fractures [2,3]. Overall, the results of this study underscore the impor­ directly to a clinical situation because it is not possible to simulate all the
tance of incorporating reinforcement techniques such as Ribbond fibres conditions of the oral cavity in an in vitro study.
and GFPs to enhance the mechanical integrity and longevity of anterior
tooth restorations. 6. Conclusions
Statistical analysis of the means of fracture resistance of all groups
revealed a significant interaction between the core type and presence of Within the limitations of this study, the following conclusions can be
ferrule. This interaction emphasizes their combined effect on fracture drawn:
resistance. Specifically, within the ferrule group, specimens with
Ribbond-reinforced composite cores exhibited the highest fracture Effect of Core Types: In the presence of a ferrule, ETAT with RIB-DC
resistance means, significantly differing from other subgroups. This cores demonstrated significantly higher fracture resistance than
stresses the critical role of core material selection alongside the presence those with GFP-DC and DC cores. No significant differences were
of a ferrule in determining overall restoration fracture resistance. The observed among core types without a ferrule.
results of the current study are in accordance with those of another study Influence of Ferrule: The presence of a ferrule significantly
[22]. which reported a statistically significant increase in fracture enhanced fracture resistance of ETAT.
resistance of ETT with Ribbond fibre under composite restorations. Failure Modes: DC and RIB-DC cores exhibited more repairable
However, two studies [21,22] used static fracture resistance testing failures, while GFP-DC cores had the highest rate of catastrophic
without subjecting the specimens to mechanical loading and thermal failures. Ferrule presence increased the likelihood of catastrophic
cycling. A study that included thermal cycling reported that Ribbond failures.
fibres reinforcement restored 85% of the original strength of the teeth
emphasizing the benefits of using Ribbond fibres in composite restora­ CRediT authorship contribution statement
tions [14].
In the no ferrule group, the results of fracture resistance demon­ Zakereyya S.M. Albashaireh: Writing – review & editing, Valida­
strated no significant differences among the fracture load means of the tion, Supervision, Project administration, Methodology, Funding
specimens in different core materials. This suggests that none of the core acquisition, Formal analysis, Conceptualization. Yasmeena K. Sbeih:

6
Z.S.M. Albashaireh and Y.K. Sbeih Journal of Dentistry 147 (2024) 105106

Writing – original draft, Software, Methodology, Investigation, Data [18] V. Chaudhary, B. Shrivastava, H.P. Bhatia, A. Aggarwal, A.K. Singh, N. Gupta,
Multifunctional ribbond-a versatile tool, J. Clin. Pediatr. Dent. 36 (4) (2012)
curation.
325–328.
[19] T. Sáry, S. Garoushi, G. Braunitzer, D. Alleman, A. Volom, M. Fráter, Fracture
Declaration of competing interest behaviour of MOD restorations reinforced by various fibre-reinforced
techniques–an in vitro study, J. Mech. Behav. Biomed. Mater. 98 (2019) 348–356.
[20] M.C. Vitale, C. Caprioglio, A. Martignone, U. Marchesi, A. Botticelli, Combined
This is to explicitly declare that the authors have no known technique with polyethylene fibres and composite resins in restoration of
competing financial interests or personal relationships that could have traumatized anterior teeth, Dent. Traumatol. 20 (3) (2004) 172–177.
appeared to influence the work reported in this manuscript (Post arti­ [21] T.G. Garlapati, J. Krithikadatta, V. Natanasabapathy, Fracture resistance of
endodontically treated teeth restored with short fiber composite used as a core
ficial aging effect of ferrule presence and core composite material on material—An in vitro study, J. Prosthodont. Res. 61 (4) (2017) 464–470.
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[23] J. Juloski, I. Radovic, C. Goracci, Z.R. Vulicevic, M. Ferrari, Ferrule effect: a
Acknowledgment literature review, J. Endod. 38 (1) (2012) 11–19.
[24] A.C.L. Faria, R.C.S. Rodrigues, R.P. de Almeida Antunes, M. da Gloria Chiarello de
Mattos, R. Faria Ribeiro, Endodontically treated teeth: characteristics and
The authors thank the Deanship of Research at Jordan University of considerations to restore them, J. Prosthodont. Res. 55 (2) (2011) 69–74.
Science and Technology, P.O. BOX 3030, Irbid 22110, Jordan for their [25] W. Martin, C. Taylor, S. Jawad, R.V. Roudsari, J. Darcey, A. Qualtrough, Modern
financial support of this work [Grant No. 2022/0111]. endodontic principles, part 7: the restorative interface, Dent. Update 43 (4) (2016)
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