In wk?

fractures of endodontically treated

posterior teeth restored with enamel-bonded
resin
Hansen EK, Asmussen E. In vivo fractures of endodontically
treated posterior teeth restored with enamel-bonded resin. Endod
Dent Traumatol 1990; 6: 218-225.
Abstract - The cumulative survival rate of 190 endodontically
treated posterior teeth were assessed in a retrospective study;
all teeth had an MO/DO or an MOD cavity restored with a
composite resin without cuspal overlays after previous acid-etching
of the enamel. In contrast to our previous study on endontically
treated posterior teeth restored with amalgam, the survival rate
of the MOD resin-restored teeth was equal to that of MO/DO
teeth. Teeth restored with a light-activated resin had a much
lower survival rate than teeth restored with a chemically-activated material, the cause presumably being that the light-activated resins were insufficiently irradiated. Nearly 25% ofthe
teeth had been restored with a microfilled resin for anterior use
and these teeth had a lower survival rate than had teeth restored
with a macrofilled or hybrid resin. It was also found that a beveling
technique did not decrease the fracture rate while the use of an
intermediate layer of low-viscosity resin resulted in a significant
improvement.

An endodontically treated posterior tooth runs a

higher risk of fracture than does a vital one (1-3).
It is not only the cavity width, but especially the
cavity depth that weakens the tooth (4), and the
high fracture rate of endodontically treated teeth
presumably is caused by the cavities being deeper
than in vital teeth (3, 5). A main problem is that
the cusp deflection in an endodontically treated posterior tooth, with a given occlusal loading, is markedly increased compared with a vital tooth (3). The
cusp flexure, and thereby the fracture susceptibility,
cannot be decreased with an intra-coronal amalgam
restoration or resin without prior acid-etching;
many studies have shown that the fracture resistance
of amalgam-restored and non-etched resin-restored
teeth is equivalent to that of teeth with an unrestored cavity (3, 6-11).
An alternative treatment option, enamel-bonded
resin, has been tested in many laboratory studies (3,
6-15); in by far the most of these papers it is concluded that the fracture resistance of teeth with an
MOD cavity may be significantly increased if the

218

Erik Keith Hansen, Erik Asmussen

Institute of Dental Materials and Technology,
Royal Dental College, Copenhagen, Denmark

Key words: acid etch-resin technique; resin restoration; tooth tracture; cusp fracture.
Erik Keith Hansen, Heisingorsgade 7, DK-3400
Hillerod, Denmark
Accepted for publication April 6, 1990.

teeth are restored with an etch-retained resin filling

instead of amalgam. This has been confirmed in an
in vivo study on endodontically treated premolars
restored with either amalgam or enamel-bonded
resin (16): the survival rate (retention of both cusps)
ofthe resin-restored teeth was markedly better than
that of the teeth restored with amalgam. In that
study (16), however, the number of resin-restored
teeth was rather small (n = 40).
The purpose of this retrospective study was to get
a more comprehensive knowledge ofthe cumulative
survival rate and the fracture pattern of endodontically treated posterior teeth restored with enamelbonded resin with or without the use of a dentinbonding agent.

Material and methods

The data were collected from January 1988 to September 1989 from 56 dentists working as general
practitioners. The results from the previous investigation (16) were updated and included in the pres-

Fracture of resin-restered endedontically treated teeth

ent study. All data were derived from clinical examinations and review of the patients' dental records
and radiographs.
The criteria for including data were: i) an endodontically treated premolar or first or second molar
with an MO, a DO, or an MOD cavity restored
with enamel-bonded resin with or without the use
of a dentin-bonding agent; ii) no cuspal overlays;
iii) no Class V restoration; iv) normal functional
occlusion; v) complete dentition in the anterior and
premolar region including cases with dental bridges
restoring one tooth in the premolar area or two
teeth in the anterior area; and vi) at least one molar
in each quadrant involved in the occlusion. Endodontically treated teeth without antagonist were not
included.
The dentists were asked to record the following
data on a registration form: tooth number, date
of endodontic therapy, cavity type (MO, DO, or
MOD), and the date of control or last contact.
The dentists were also asked to record the cavity
preparation (bevel or butt-joint), use of intermediate layer of low-viscosity resin, application technique (bulk or increment), name of restorative resin,
and name of dentin-bonding agent, if used.
In cases of fracture, the dentists were asked to
record the date of tooth failure and whether the
facial cusp, the lingual cusp, or the whole crown
(total fracture) was lost. The dentists were also
asked to record whether the fracture was supragingivai, subgingival, at or beyond the alveolar crest,
or whether the fracture was so vertical that the
tooth had to be extracted. In the following, fractures
at or beyond the alveolar crest, but not vertical
fractures resulting in extraction, are referred to as
subcrestal, even though some of these fractures may
have had a fracture level slightly above the alveolar
crest.
The survival time was defined as the time elapsed
between the date of endodontic therapy and the
date of fracture, the date of final registration, the
date of last contact with the patient, or the date of
withdrawal (change of cavity, change of restorative
material, extraction ofthe antagonist). In the analyses, no distinction was made between MO and DO
restorations: only between MO/DO and MOD.
When MO/DO restorations had been replaced by
MOD filhngs, the teeth were recorded as withdrawn
from the MO/DO category and entered among the
MOD teeth.
In the previously mentioned study on endodontically treated posterior teeth restored with amalgam (5), the teeth could be divided into three
groups with different survival rates: Group A consisted of all premolars and molars with MO/DO
cavities except upper second premolars; Group B
consisted of upper second "MO/DO premolars".

lower "MOD premolars" and upper and lower

"MOD molars"; and Group G consisted of upper
"MOD premolars". The same grouping was used
in the present study. The cumulative survival rate
for each group was calculated with life table analysis
(17). Differences between the three groups were
analyzed with log-rank tests (17) at the 5% level of
significance. Analyses of the fracture pattern and
differences as to type of restorative resin and treatment of the cavo-surface margin were done with
contingency tables, Kruskal-Wallis one-way analysis of variance, Mann-Whitney's U test, and the
Fisher exact probability test (18). The significance
level for the use of low-viscosity resin and for the
fracture pattern was set to 1%; the reason for this
will be explained in Results.
Most of the analyses were carried out with a
computerized statistical program (MEDSTAT, version 2.1, Astra, Gopenhagen, Denmark).
Results
Data were obtained on 213 endodontically treated
posterior teeth restored with resin, but 11 teeth
were rejected because the cavity type or the date of
endodontic therapy was not recorded or because of
cuspal overlays. A further 12 sets of data were partly
rejected because some ofthe dentists misunderstood
the instructions and only recorded fractured teeth,
not fractured and non-fractured at random. These
12 teeth were excluded from the survival analyses,
but included in the analyses of the fracture pattern.
Table 1 shows the 190 teeth in the survival analyses
distributed by cavity type and fracture mode.
In this article, no distinction is made between
teeth from the right side of the mouth and teeth
from the left side. In the tables, only right side tooth
numbers will be used.
Survival rate (retention of both cusps)
The number of endodontically treated teeth distributed by tooth number, cavity type, and fracture
mode are shown in Table 1.
There was no statistically significant difference
between the cumulative survival rates of Groups A,
B and G (P = 0.98), i.e., teeth with an MOD cavity
had the same failure rate as teeth with an MO/DO
cavity. The survival rates of the three groups are
depicted in Fig. 1, and the 95% confidence intervals
are shown in Table 2 for the 3-, 5-, and 10-year
survival rates. With no statistically significant difference between the three groups, the pooled cumulative survival rate was calculated for a further two
years; 11 years: 72% (n = 28), and 12 years: 72%
(n= 19). The 95% confidence limits were 57-87%
for 11 years and 52-92% for 12 years. The 12-year
219

Hansen & Asmussen

Table 1. Number of endodontically treated teeth in the survival analyses distributed on tooth number, cavity type, and fracture mode.
Cavity type
Facial

Tooth
number^
14
15
16
17
44
45
16
47
14
15
16
17
44
45
46
47

Fracture mode^

MO/DO

-f-

6
3
4
1
4
5
4
1
7
1
1
1
4
3
0
1

MOD

MO/DO

Lingual

MOD

21
13
5
0
0
5
1
3
44
28
6
0
4
8
4
1

MO/DO

Total

MOD

2
1

2
1
1

5
4

MO/DO

MOD

' = No vertical fractures were found.

- = Viohl's two-digit system.
' = Use of dentin-bonding agent.

survival rate will be used in the Discussion where a

comparison is made between the failure rate of acidetch resin-restored teeth and amalgam-restored
teeth.
The cumulative survival rate of the resin-restored
teeth depended on several variables:
Restorative resins - The endodontically treated

/o

100

teeth had been restored with 20 different resins.

Analyses ofthe survival rates of 190 fillings with so
many materials are not possible. The teeth were
therefore first divided into two groups: Teeth restored with a chemically-activated and teeth restored with a light-activated resin.
Teeth restored with a chemically-activated resin
had a 5-year cumulative survival rate of 92% in
contrast to 59% for teeth restored with a lightactivated material (the 95% confidence limits were
87-98% and 29-89%, respectively). This difference
was highly significant ( P < 0.001). Even the 10-year
survival rate of teeth restored with a chemically-

LU

< 80

B
A
C

Table 2. Cumulative survival rates of Groups A, B, and C with 95% confidence

limits in parenthesis.

60

Tooth number'

CO
UJ
>

Group
(n)

<

A
(42)

Z)

20

B
(41)

2
A
6
8
10
YEARS AFTER TREATMENT

12

Fig. 1. Cumulative survival rates of resin-stored teeth with an

MO/DO cavity (A) or an MOD cavity (B and C). For a detailed
explanation of A, B, and C: see Table 2.

220

Cavity type
MO/DO

MOD

14,
44,45
16,17
46,47
15

C
(107)

Cumulative survival rates (%)

3 years

5 years

10 years

92 (81-100) 81 ( 6 ^ 9 9 )

73 (40-100)

44,45
16,17
46,47

89(78-100)

85(70-100)

78(46-100)

14,15

94 (89-99)

89 (81-96)

71 (56-87)

93 (88-97)

87 (80-93)

72 (59-85)

C(190)
^ = Viohl's two-digit system.

Hansen & Asmussen

o/
/o

lingual and facial failure was not statistically significant (P=0.12). There also was a tendency for "molar fractures" to be more severe than "premolar
fractures", but a detailed analysis was not made
because of the small number of molar fractures
(Table 1). None of the 32 fractures was so vertical
that the tooth had to be extracted.

100
LU

80

> 60
Discussion
CO

>
1

20

2
A
6
8
10
YEARS AFTER TREATMENT

12

Fig. 3. Comparison of survival rates for resin-restored and amalgam-restored teeth. AA = Amalgam, Group A. AB = Amalgam,
Group B, AC = Amalgam, Group C. R = Resin, Groups A, B
and C pooled.

expected number of fractures in the beveled and in

the non-beveled group.
Fracture pattern
In our previous study on endodontically treated
teeth restored with amalgam (5), three analyses of
the fracture pattern could be made: tooth surface,
fracture level, and effect of tooth position in the jaw.
Only the two first analyses were made in this study
because upper premolars made up more than 65%
of the resin-restored teeth.
Tooth surface - Most of the fractures involved the
facial cusp. For the upper first premolar, 7 1 % of
the fractures were found facially while the pooled
frequency of facial cusp fracture for the other posterior teeth was 50%; this difference was not statistically significant (P=0.39). No difference was found
between teeth restored with a light-activated resin
and teeth restored with a chemically-activated material {P=0A6).
Fracture level - There were more subgingival and
subcrestal fractures for teeth restored with a lightactivated resin than for teeth restored with a chemically-activated material (P= 0.048); this difference
was not considered as statistically significant because 24% of the fractured teeth had no recorded
fracture level.
Lingual fractures caused more periodontal damage than did facial ones, but the difference between
222

In a retrospective study, a registration form with too

many questions may result in a reduced response.
Furthermore, some of the answers may have been
based upon memory, not upon actual knowledge.
Thus, several variables were not included in the
registration form, first of all variables that may have
been important for the assessment of the low success
rate of the light-activated resins, e.g. matrix system
(metal or clear strips), the use of light guiding
wedges, the thickness of the increments, and final
irradiation from the facial and lingual aspect of the
tooth. Not only this lack of information, but also
the high proportion of unrecorded use of a lowviscosity resin and unrecorded fracture levels call
for a cautious interpretation.
Nevertheless, the high failure rate of teeth restored with a light-activated material is astonishing
(Fig. 2); the statistical analyses showed that teeth
restored with a light-activated resin had nearly
three times as many fractures as expected (the number of expected fractures is derived from the logrank tests). It should once again be noted that all
light-activated resins were applied with a layering
technique.
There may be several causes for the low survival
rate of teeth restored with a light-activated resin,
but the main one is presumably the initiation of
the polymerization process: teeth restored with a
chemically-activated microfilled resin for anterior
use had a higher survival rate than teeth restored
with the corresponding light-activated material for
anterior use (e.g. the chemically-activated Silar vs
the light-activated Silux); and the same was found
for resins intended for posterior use (e.g. the chemically-activated resion P-10 vs the two light-activated resins, P-30 and P-50). Even old-fashioned
macrofilled resins like Concise and Adaptic gave
better survival rates than did modern light-activated
resins provisionally or finally accepted for posterior
use by the American Dental Association: Estilux
Posterior, Fulfil, Heliomolar, Herculite, and Occlusin, all of which were used in the present study. This
problem, polymerization of light-activated resins in
posterior teeth, should therefore be discussed in detail.
Out of the 190 endodontically treated teeth, 25 were
restored with a light-activated microfilled resin for

Fracture of rosin-restored endoiionticaily treated teeth

anterior use, solely Durafill or Silux (Table 3). For
both restoratives, the manufacturers recommend an
irradiation time of 20 or 40 sec dependent on the
opacity of the shade. But one may get a very low
conversion in the restorative resin if such a short
irradiation time is used to polymerize the first increment in the cavity of an endodontically treated
posterior tooth; the cavity is very deep and the
distance between the exit window of the lamp and
the first layers of resin is markedly larger than that
found in most anterior cavities. As to hght-activated
posterior resins, the normally recommended irradiation time is 40 sec; this may still be too short
a time to get a sufficient conversion of the first
increments in such deep cavities. The irradiation
time may be a very essential cause for the poor
results obtained with the light-activated resins (Fig.
2).
When light-activated restoratives are used, most
manufacturers recommend that one does not use
layers thicker than 2 mm. But even a 2 mm layer
may be too thick in the deeper part of the cavity of
endodontically treated posterior teeth. The cause
for the high failure rate of teeth restored with a
light-activated resin may thus be that the hghtactivated resins were insufficiendy irradiated and/
or the increments were so thick that the restoration
actually had no strengthening effect at all.
There were 45 teeth which had been restored
with a microfilled resin for anterior use (Table 3).
All but three of the microfilled restorations were
found in premolars presumably because of esthetic
considerations: high-polished surfaces and many different shades to choose between. But as seen in Fig.
2, these restorative resins gave the lowest survival
rate in both the light-activated and the chemicallyactivated group. The low survival rates strongly
indicated that microfilled restoratives should not be
used in endodontically treated posterior teeth,
which are in occlusion, especially since an increasing
number of hybrid resins for posterior use are available in many shades.
The fracture resistance of teeth restored with resin, which have been both enamel-bonded and dentin-bonded, has been tested in several laboratory
studies (9, 11, 13, 15, 17-22). But there is a pronounced variety in especially the cavity design in
these in vitro studies, and the results are contradictory. As pointed out by Reel and Mitchell (15),
the main problem is that there is no standardized
method for testing the fracture resistance of prepared teeth. Therefore a comparison of results obtained with different in vitro tests is very difficult, if
not impossible. In our study, the use of dentinbonding agents did not reduce the fracture rate.
However, 65 out of the 77 teeth, where dentinbonding agents were used, were restored with a

light-activated resin, and one cannot expect an improved survival rate if the restorative resin is pooriy
polymerized.
The use of an intermediate layer of low-viscosity
resin resulted in a pronounced improvement of the
survival rate for teeth restored with a chemicallyactivated material, but not for teeth restored with
a light-activated one. The cause for this difference
may be the following:
In vitro studies have shown that an acid-etched
enamel surface is fragile (23, 24): even a very light
pressure may result in a significant reduction in the
bond strength between resin and etched enamel.
But if the enamel has been covered with a lowviscosity resin prior to application of the restorative
resin, the risk of impairing the bond strength may
be significantly reduced. An additional explanation
could be that both the amount and the size of
marginal voids is increased when no intermediate
resin layer is used (25). Marginal voids will reduce
the contact area between resin and enamel, and
fewer sites are therefore available to hinder the wallto-wall shrinkage of the polymerizing restorative
resin. The result may be the formation of a partial
or total gap between the restorative resin and the
cavity wall, and thereby a diminished capability of
the resin restoration to increase the strength of the
tooth. The reason why the use of a low-viscosity
resin did not improve the survival rate of teeth
restored with a light-activated resin conceivably is
that an increased contact area between the restorative resin and the etched enamel is of no value if
the restorative material is pooriy polymerized.
The fracture resistance of prepared teeth with a
beveled cavo-surface margin has been tested in vitro
(8, 11, 15). These studies all show no, or only a
sHght, improvement of the tooth strength, which is
in agreement with the present investigation.
The survival rate of the acid-etch resin-restored
teeth in this study may be compared with that of
the corresponding amalgam-restored teeth in our
previous investigation (5). This comparison is depicted in Fig. 3 where the pooled 12-year survival
rate of the resin-restored teeth is applied. As seen,
amalgam-restored MO/DO teeth had a slightly
better 12-year survival rate than that found for the
pooled MO/DO and MOD resin-restored teeth, but
the difference was not statistically significant {P>
0.2). One may argue that a comparison between
the survival rate of amalgam-restored MO/DO
teeth and pooled MO/DO plus MOD resin-stored
teeth is incorrect, but as reported in Results, the
statistical analyses showed that there was no significant difference between MO/DO and MOD cavities
when the teeth were restored with enamel-bonded
resin (Fig. 1, Table 2).
This is not the case when the teeth are restored

223

Hansen & Asmussen

with amalgam (5). Teeth with MOD amalgam restorations, especially upper premolars, have a pronouncedly higher failure rate than that found for the
acid-etch resin-restored teeth with MOD cavities;
already after one year, the difference between the
survival rate obtained with the two types of restorative methods is statistically significant at the level of
probability below 0.05 (Group B) and below 0.001
(Group C). The difference between the 12-year survival rates of resin- and amalgam-restored MOD
teeth was highly significant at a level of probability
far below 0.001 (Fig. 3). It should be noted that the
high survival rate of the resin-restored MOD teeth
in this study was obtained in spite of the poor results
found with the light-activated materials (Fig. 2).
The periodonal damage caused by the cusp fractures of the acid-etch resin-restored teeth was not
as severe as found in our previous study where
amalgam was used as the restorative material (5).
A possible reason for this may be that the strengthening effect of an etch-retained filhng will give a
more coronal fracture in case of cusp failure. This
holds thrue only ifthe restorative resin is sufficiently
polymerized. The fracture resistance of teeth restored with an insufficiently irradiated resin filling
appeared to be equivalent to that of an unrestored
cavity. Our hypothesis, insufficient polymerization
of some of the light-activated restorations, was supported by the fact that teeth restored with these
materials had more subgingival and subcrestal fractures than had teeth restored with chemically-activated resins. In the latter group, all but one fracture
were supragingival. Even including the fractures of
light-activated resins, the periodontal damage in
case of tooth failure was less severe than found for
the amalgam-restored teeth in out previous study
(5):

Conciusions and recommendations

1. The acid-etch resin technique may be a better
treatment option than amalgam for temporary or
permanent restoration of endodontically treated
posterior teeth, especially teeth with an MOD
cavity.
2. Light-activated resins must be polymerized properiy. We suggest at least 60 s per increment.
3. The increments in the proximal part of the cavity
should be less than 2 mm thick.
4. Microfilled resins intended for anterior use
should not be used to restore posterior teeth.
5. The acid-etched enamel should be covered with
an intermediate layer of low-viscosity resin.
6. Beveling the cavo-surface margin does not improve the survival rate of endodontically treated
posterior teeth restored with the acid-etch resin
technique.

224

Acknowledgements - The authors want to thank the

dentists who collected the information on which our
study is based. This investigation was supported by
the Research Foundation of Dental Aktieselskabet
af 1934, the Insurance Association of Danish Dentists in Hafnia Insurance, and the Research Foundation of the Danish Dental Association.

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225