RESEARCH AND EDUCATION

Effects of different cusp coverage restorations on the fracture

resistance of endodontically treated maxillary premolars
Tugba Serin Kalay, DDS, PhD,a Tahsin Yildirim, DDS, PhD,b and Mustafa Ulker, DDS, PhDc
Endodontically treated teeth
ABSTRACT
(ETTs) are believed to be weak
Statement of problem. Cusp coverage restorations for the restoration of endodontically treated
and brittle because of the
teeth represent a more conservative approach in terms of function and esthetics. However, limited
extensive loss of coronal and
scientic data are available regarding the optimum reduction design and thicknesses.
radicular tooth structure.1-3 This
Purpose. The purpose of this in vitro study was to evaluate the fracture resistance and fracture
decreases fracture resistance
patterns of cusp coverage restorations with different cusp reduction designs and reduction thickand increases cusp deection
nesses on endodontically treated maxillary premolars (ETMPs) with mesio-occluso-distal (MOD)
under functional forces. Endcavities.
odontic access cavities comMaterial and methods. One hundred sixty-ve extracted intact human maxillary premolars were
bined with mesio-occluso-distal
divided into 11 groups: G1-10 (test groups) and G11 (intact group). In the test groups, all of the
(MOD) cavity preparations
teeth were restored with composite resin after canal treatments with MOD cavities. However, the
dramatically increase cuspal
cusps of the G1-9 teeth were reduced with combinations of different thicknesses (1.5, 2.5, and
3.5 mm) and designs (beveled, horizontal, and anatomic). The specimens were subjected to 105
deection and lead to increased
4,5
cycles of 50 N mechanical loading. Next, the specimens were subjected to a compressive load at
tooth fragility.
a crosshead speed of 0.5 mm/min until fracture. The fractured specimens were analyzed to
Clinical surveys show that
determine the fracture pattern. Two-way ANOVA followed by the Fisher least signicant
ETTs with ideal coronal restodifference (LSD) test was used to analyze the interaction between groups.
rations are crucial for long-term
Results. The fracture resistance values increased with increases in the cusp reductions. The fracture
clinic success. The majority of
resistance values of the G6 (2.5 mm, anatomic) and G9 (3.5 mm, anatomic) groups were signicantly
ETTs are lost because of coronal
greater than that of the MOD group. However, the G6, G8 (3.5 mm, horizontal), and G9 groups were
restoration failures in the longcomparable with G11. The highest restorable fracture rates were observed in G6 and G9.
6
term. An ideal coronal restoConclusions. Cusp reduction design and thickness inuenced the fracture resistance and fracture
ration preserves the root canal
patterns of cusp coverage restorations of ETMPs with MOD cavities. The teeth restored with
system, supports the remaining
anatomic cusp reduction designs with reduction thicknesses of at least 2.5 mm exhibited greater
tooth structure, and restores
fracture resistance and more frequent restorable fractures. (J Prosthet Dent 2016;-:---)
7
tooth function.
Restorations of ETTs with
adhesive techniques may conserve more tooth structure
adhesive cusp coverage restorations increase the fracture
and provide sufcient fracture strength.8-11 However, the
resistance of endodontically treated posterior teeth
direct composite resin restoration of extensive cavities
compared with direct MOD composite resin restorations.
cannot establish tooth strength, and a reliable alternative
An early study reported that cusp reductions should be
for restoration may be needed.12-14
at least 1.5 mm to reduce the stress values on the cusp
Recently, several in vitro studies15-22 and clinical recoverage adhesive restorations,25 and later studies related
14,23,24
ports
to cusp coverage restorations applied 1.5 to 3.5 mm
have found that in the protection of cavities,
a

Research Assistant, Department of Restorative Dentistry, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey.
Professor, Department of Restorative Dentistry, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey.
c
Associate Professor, Department of Restorative Dentistry, Faculty of Dentistry, Selcuk University, Konya, Turkey.
b

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MATERIAL AND METHODS

Clinical Implications
Adhesive cusp coverage MOD restorations are a
more conservative treatment than traditional
crowns for endodontically treated maxillary
premolar teeth. Teeth prepared with anatomic cusp
reduction designs and thicknesses of at least 2.5
mm exhibited greater fracture resistance and more
frequent restorable fractures.

cuspal reductions with a single type of reduction

design17-19 or applied different reduction designs with a
single reduction thickness.15,20,26 However, limited scientic data are available regarding the optimum reduction thickness and the effects of different cusp reduction
designs on the tooth-restoration complex.
Additionally, cusp fractures are among the major
reasons for the extractions of ETTs.27 Unrestorable
subgingival or vertical cusp fractures are observed
more commonly in ETTs with extensive intracoronal
restorations.28 These fractures cannot be restored, and
the majority of these situations result in the extraction
of the tooth.29,30 Studies have reported that many
factors inuence the locations and directions of
root fractures, specically, the remaining tooth structure, the cavity design, and the restorative procedures.3,13,31-34
The purpose of this study was to determine the inuences of various cusp reduction designs and thicknesses on the in vitro fracture resistances of ETMPs with
MOD cavities to identify the optimum reduction thickness and design and to evaluate whether these various
cavity designs affect the restorable fracture rate. The null
hypothesis tested was that the reduction thickness
and design would have no inuence on the fracture
resistance and fracture pattern of the cusp coverage
restoration of endodontically treated maxillary premolars
with MOD cavities.

This study protocol was approved by the Ethical

Research Committee (2014.144) of the Karadeniz Technical University. Caries-free human maxillary premolars
with two roots and two canals (extracted for orthodontic
reasons) were used. Teeth with cracks, fractures, or defects and internal-external resorption were excluded
from the study. The mesiodistal and buccolingual tooth
sizes were measured with digital calipers, and teeth with
similar dimensions were selected. The selected teeth
were assigned to 11 groups of 15 teeth each (Table 1)
and were stored in 0.2% sodium azide solution.
Before the preparations, an impression of each tooth
was made with a heavy-body silicone impression material (Optosil; Heraeus Kulzer GmbH) for use as an
anatomic guide to obtain an original form while the
restoration was applied. Endodontic and restorative
procedures were performed in groups 1 to 10, and all
procedures were performed by 1 researcher (T.S.K.).
MOD cavities were prepared without proximal steps
at the cemento-enamel junction (CEJ) and with an
occlusal isthmus width of one-half of the buccolingual
distance. The buccal and lingual walls of the occlusal
isthmus were prepared parallel to each other. The cavity
dimensions were measured with digital calipers.
For the endodontic cavity preparations, diamond
rotary cutting instruments (Dentsply Maillefer) were
used in a high-speed handpiece under copious airwater cooling. After extirpating the pulp, size 15 K
les (Dentsply Maillefer) were inserted until their tips
could be seen at the apical foramen. The working
lengths were determined by subtracting 1 mm from
this length. The endodontic treatments were performed
using NiTi rotary instruments (ProTaper; Dentsply
Maillefer). Standardized canal enlargements were performed with an engine-driven rotary NiTi system up to
F3 for the apical preparation using a crown-down
technique. Rotary instruments were used with a
torque-limited engine (X-Smart; Dentsply Maillefer).

Table 1. Fracture loads (N)

Group (G) (n=15)

MOD Cavity Characteristics

Fracture Loads
(N) Mean SD

Minimum

Maximum

G1

1.5-mm beveled reduction

870.34 139.09b

602.53

1184.07

G2

1.5-mm horizontal reduction

885.52 209.75b

524.81

1228.47

G3

1.5-mm anatomic reduction

906.97 199.86b

423.41

1187.40

G4

2.5-mm beveled reduction

851.30 173.13b

555.65

1087.62

G5

2.5-mm horizontal reduction

837.24 207.76b

449.49

1264.50

G6

2.5-mm anatomic reduction

1110.37 235.05a

751.49

1498.21

G7

3.5-mm beveled reduction

961.82 216.88b

694.00

1343.64

G8

3.5-mm horizontal reduction

1039.10 262.25a,b

599.47

1621.36

G9

3.5-mm anatomic reduction

1085.28 214.75a

792.79

1570.81

G10

No reduction

777.17 188.79b

434.64

1009.33

G11

Intact teeth

1640.80 455.76a

938.64

2194.17

Different superscript letters represent signicantly differences identied by 1-way ANOVA with post hoc Tamhane tests (P<.05).

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Serin Kalay et al

2016

Five percent sodium hypochlorite was used for irrigation during the endodontic preparation. The canals
were dried with paper points (Dentsply Maillefer), and
all roots were obturated with ProTaper F3 gutta percha
(Dentsply Maillefer) and endodontic sealer (AH Plus;
Dentsply Maillefer). The coronal part of the gutta
percha material was removed 2 mm apically to the CEJ,
and glass-ionomer cement (Ketac Molar Easymix;
3M ESPE) was then inserted into this area as a coronal
restoration.
Teeth in the G11 group were left intact as the control
group. After the endodontic treatments, teeth in the G10
group were only prepared with MOD cavities. In the
reduction groups (G1-9), after the endodontic treatments
and MOD cavity preparations, both cusps of the teeth
were reduced with combinations of different thicknesses
(1.5, 2.5, and 3.5 mm) and designs (beveled, horizontal,
and anatomic) (Table 1). In the horizontal reduction
design, the cusp reduction was prepared parallel to the
occlusal plane without bevels. In the beveled reduction
design, after the reduction of the cusps parallel to the
occlusal plane, bevel preparations were performed in an
opposite angle to the natural cusp ridge. In the anatomic
reduction design, the cusp reduction was prepared parallel to the natural cusp ridge. The reduction thicknesses
were evaluated at the reference point (cusp tip) with
digital calipers (Fig. 1A).
The prepared surfaces were selectively etched
(enamel for 30 seconds, dentin for 15 seconds) with 37%
phosphoric acid (Scotchbond Etchant; 3M ESPE), rinsed
for 20 seconds with an air/water spray, and gently airdried. A single-component bonding agent (Adper Single Bond 2; 3M ESPE) was applied to the tooth surface
with a microbrush and then air-dried for 5 seconds; then,
the surface was exposed to a light-emitting diode (LED)polymerization unit (Elipar S10; 3M ESPE). The teeth
were placed into the impression guides previously made
for each tooth, such that the cavities could not be overlled at the margins and the reduced cusps could be
restored to their original forms.
Subsequently, the cavities were lled with a posterior
composite resin (P60; 3M ESPE). The composite resin
was placed using the oblique incremental technique, and
each increment was polymerized for 20 seconds. After
the restorations were nished, the teeth were polished
with rubber cups and points (Identoex; Kerr Corp).
Water-based liquid latex (Rubber-Sep; Kerr Corp) was
applied to the roots to simulate the periodontal ligament,35 and the roots of the teeth were then embedded
in acrylic resin up to 3 mm below the CEJ using cylindrical blocks. All of the specimens were submitted to 105
cycles of the application of 50-N loading forces at a frequency of 0.5 Hz in a mastication simulation machine36,37
(Vega Chewing Simulator; Nova Tic). The mechanical
loading was applied to the center of the occlusal surface
Serin Kalay et al

Anatomic
A

3 mm

Horizontal

A=2B

Beveled

II

III

B
Figure 1. A, Cusp reduction designs and cavity dimensions. B, Fracture
patterns after fracture resistance tests.

in contact with both cusp ridges with a stainless steel

antagonist with a rounded end that was 6 mm in
diameter.38 The specimens were maintained in a humid
environment throughout the mastication simulation.
After the articial aging procedures, the specimens were
subjected to a compressive load at a crosshead speed
of 0.5 mm/min in a universal testing machine (Instron
3382; Instron Corp).
The compressive load was applied parallel to the long
axis of the tooth with a 6-mm-diameter stainless steel
antagonist placed in the center of the tooth with contacts
only on the buccal and lingual cusps. The force required
for fracture was recorded in newtons. The fractured
specimens were analyzed to determine the fracture patterns according to the location of the fracture as follows
(Fig. 1B): type I, coronal fractures involving small
amounts of enamel/composite resin (restorable); type II,
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Table 2. Distribution of fracture patterns for each group

Fracture Pattern % - (n)
Restorable
Group (G)

Type I

G1 (1.5-mm beveled)

Type II

Nonrestorable
Type III

6.7 (1)

6.6 (4)

66.7 (10)

G2 (1.5-mm horizontal)

6.7 (4)

73.3 (11)

G3 (1.5-mm anatomic)

6.7 (1)

20.0 (3)

73.3 (11)

G4 (2.5-mm beveled)

6.7 (1)

33.3 (5)

60.0 (9)

G5 (2.5-mm horizontal)

20.0 (3)

80.0 (12)

G6 (2.5-mm anatomic)

20.0 (3)

26.7 (4)

53.3 (8)

G7 (3.5-mm beveled)

33.3 (5)

66.7 (10)

G8 (3.5-mm horizontal)

33.3 (5)

66.7 (10)

G9 (3.5-mm anatomic)

26.7 (4)

26.6 (4)

46.7 (7)

13.3 (2)

86.7 (13)

60.0 (9)

26.7 (4)

13.3 (2)

G10 MOD)
G11 (Intact teeth)

coronal cusp fractures involving the dentin at a maximum

of 1 mm below the CEJ (restorable); type III, vertical
root/coronal fractures greater than 1 mm below than CEJ
(nonrestorable) (Table 2).
A power analysis revealed a power of 93.02% for this
study. The statistical analyses were performed with the
Shapiro-Wilk test for normal distributions and 1-way
analysis of variance (ANOVA) followed by the Tamhane tests. Two-way ANOVA followed by the Fisher
least signicant difference (LSD) test was used to analyze
the interaction between the cusp reduction thicknesses
and the designs of the reduction groups (a=.05 for all
tests).
RESULTS
The data exhibited normal distributions according to the
Shapiro-Wilk tests. Regarding the control and reduction
groups, the 1-way ANOVA revealed signicant differences (P<.001) among all groups. A Tamhane test
revealed differences between the reduction groups and
the control group (Table 1). All of the reduction groups
exhibited higher fracture resistances than the MOD
group. Signicantly higher fracture resistance values
were observed in 2 reduction groups (2.5-mm anatomic
and 3.5-mm anatomic) compared with the MOD group.
Additionally, similar fracture resistance values were
observed in the G6 (2.5-mm anatomic), G8 (3.5-mm
horizontal), and G9 (3.5-mm anatomic) group relative
to the intact tooth group. The 2-way ANOVA followed
by the Fisher LSD tests indicated differences in terms
of the interaction between reduction thickness and
reduction design.
Different designs were compared, and the results
are graphically displayed in the box plots in Fig. 2. No
signicant differences between any of the reduction
designs were observed at the 1.5-mm and 3.5-mm
reduction thicknesses. Regarding the 2.5-mm thickness,
the anatomic reduction design exhibited a signicantly
THE JOURNAL OF PROSTHETIC DENTISTRY

Issue

higher fracture resistance compared with the horizontal

and beveled groups.
The thicknesses of the 1.5-, 2.5-, and 3.5-mm reductions were compared (Fig. 3). No signicant differences among the reduction thicknesses were observed
with the beveled reduction design. Regarding the horizontal design, the 3.5-mm thickness exhibited a signicantly higher fracture resistance than the 1.5- and
2.5-mm thicknesses. Regarding the anatomic design, the
2.5- and 3.5-mm thickness groups exhibited signicantly
higher fracture resistances than the 1.5-mm thickness
group.
The intact teeth predominantly fractured with
restorable patterns; conversely, the teeth in the MOD
group fractured with nonrestorable patterns. In the
reduction groups (G1-9), the highest restorable fracture
rates were observed in the 2.5-mm and 3.5-mm anatomic
reduction groups; furthermore, 80% of the fractures in
the anatomic reduction design group exhibited type I
patterns (Table 2).
DISCUSSION
In the present study, the fracture resistances of ETMPs
restored with various cusp coverage restorations were
evaluated. Many factors may inuence in vitro results;
thus, in vitro experiments should represent the intraoral
environment. Simulations of periodontal ligaments can
inuence not only the fracture load values but also the
fracture patterns.35 For these reasons, the roots of the
teeth were covered with latex liners.
Changes in the mechanical properties of a restoration
under masticatory load and fatigue failures after a period
of clinical use are important. A masticatory simulator
was used to simulate the clinical conditions that occur
during mastication with the intention of mimicking
at least 1 year of in vivo clinical use. Restorations are
thought to undergo 1 000 000 active stress cycles in
20 years.37 In the present study, 105 cycles of mechanical
loading were applied at a frequency of 0.5 Hz, which
is close to the masticatory cycle in vivo.36
Maxillary premolars were used in this study because
their anatomy is susceptible to cusp deection and fracture under occlusal loads.9 The removal of tooth structure
for endodontic and restorative procedures increases
cuspal deection and susceptibility to fracture and also
affects the restoration type. Cusp coverage becomes
necessary when the width of the cavity isthmus is greater
than two thirds of the intercuspal distance or one half of
the buccolingual distance.21 In our study, the width of
the MOD cavity isthmus was prepared to be one half
of the buccolingual distance.
Restorations of ETTs with adhesive methods support
the remaining tooth structure, prevent additional
tissue loss and exhibit more homogeneous distributions
Serin Kalay et al

P = .313

Anatomic
2.5

Group

Beveled

P = .00

Horizontal

P = .854

P = .108

P = .01

Beveled

1.5

Anatomic

P = .779

Horizontal

P = .843

Beveled

500

750

1000

1250

1500

P = .632

1750

Load (00)

Group

P = .546

3.5

P = .150

2.5

P = .803

P = .223

1.5

Horizontal

3.5

Anatomic
Horizontal

Beveled

2016

3.5

Anatomic

3.5

P = .009

2.5

P = .528

1.5

P = .046

P = .743

2.5

P = .021

P = .009

1.5

500

750

1000

1250

1500

1750

Load (00)

Figure 2. Box plots of load to fracture test (N). Comparison of reduction

groups with identical reduction thicknesses and different reduction
designs.

Figure 3. Box plots of the load to fracture test (N). Comparison of

reduction groups with identical reduction designs and different reduction thicknesses.

of occlusal forces.8,14,20,22 The use of bonded cuspal

coverage restorations, such as onlays, overlays, and
endocrowns, for the restoration of ETTs with large
structural losses represents a more conservative approach
in terms of function and esthetics.14,17,18
Although earlier studies reported that bonded
cusp coverage restorations improve fracture resistance,14,15,18-20,23-26 the literature remains unclear regarding which cusp reduction thicknesses and designs
are optimal for weakened ETTs. In the present study,
3 different cusp reduction designs (anatomic, horizontal,
and beveled) were applied at 3 different thicknesses
(1.5, 2.5, and 3.5 mm) to obtain the optimum reduction
thickness and design within the limitations of the study.
The results of the present study support the existence
of differences in the resistance to fracture and the mode
of failure between cusp coverage restorations of ETMPs
with MOD cavities according to various reduction
thicknesses and designs. Cusp reduction was found to
increase the fracture resistances of ETMP restorations
with extensive MOD cavities compared with restoration
without cusp coverage. The 2.5-mm anatomic and 3.5mm anatomic groups exhibited signicantly increased
ETMP fracture resistances compared with the MOD
group. The results from the 2.5-mm anatomic, 3.5-mm
horizontal, and 3.5-mm anatomic groups were statistically similar to those of the intact teeth, and these ndings agree with those of other studies.18,26 Moreover,
some studies have reported that cusp coverage restorations improve fracture resistance compared with MOD
restorations, but the fracture resistances of such restorations remain signicantly below those of intact teeth.9
Magne et al17 evaluated the inuences of overlay
thickness (1.5, 2.5, and 3.5 mm) on the in vitro fatigue
resistances and failure modes of endodontically treated

premolars. These authors used only a single type of

reduction design and reported that thick composite resin
overlays increased the fatigue resistances of endodontically treated premolars compared with thin overlays.
Mondelli et al18 investigated the inuences of 2-mm
overlay thicknesses in a single type of reduction design
on the fracture resistances and fracture modes of
endodontically treated premolars with MOD cavities and
found that the cusp coverage resulted in fracture resistances similar to those of sound teeth. The present
study conrmed these results, nding that cusp reduction
increased fracture resistance.
Studies related to cusp coverage restorations of
extensive MOD cavities have applied different cusp
reduction designs. Krifka et al20 evaluated cusp coverage
methods with a horizontal reduction design of the cusps.
Mondelli et al18 and Magne et al17 evaluated cusp
coverage restorations with reductions parallel to the cusp
incline. Dejak et al15 evaluated different onlay designs
with horizontal, beveled, and rounded shoulder preparation designs and reported that onlays with rounded
shoulder margins exhibited favorable stress distributions
between the restorations and the tissues.
In the present study, the fracture resistances of the
restored premolars with various cusp reduction designs
were different. The anatomic cusp reduction design
signicantly strengthened the teeth. When the results of
the cusp fracture patterns were assessed, the greatest
proportion of restorable fractures among the reduction
groups was also observed in the anatomic reduction
groups. This nding is most likely due to the axial direction of the cusp reduction design, which would lead to
a favorable distribution of occlusal forces and transfer to
the tooth structure when a compressive load is applied.
Additionally, this nding might be attributable to the

Serin Kalay et al

THE JOURNAL OF PROSTHETIC DENTISTRY

improved resistance to fracture associated with beveled

margins. Beveled margins have been reported to enhance
the properties of restored teeth compared with nonbeveled cavities.10,11,32 The importance of the loading
area and the cusp inclination34,38 and location of the
remaining tooth structure3,33 has previously been reported in in vitro studies. With overlay restorations,
favorable cusp inclinations, occlusal contacts and favorable remaining tooth structure locations with adequate
cusp reduction preparations can be provided.
These ndings suggest that both cusp reduction
design and thickness inuence the fracture resistances of
ETMP restorations. Cusp reductions with all of the
thicknesses and designs used in this study improved the
fracture resistances compared with the MOD cavity
design. However, according to the statistical results and
fracture patterns observed in this in vitro study,
anatomic reduction designs with at least 2.5-mm-thick
reductions are a safe option because such treatments
limit the risk of nonrestorable cusp fractures of cusp
coverage restorations of ETMPs with extensive MOD
cavities.
CONCLUSIONS
Adhesive cusp coverage restorations increased the fracture resistances of ETMPs with MOD cavities to a level
comparable with that of intact teeth. The cusp reduction
designs and thicknesses inuenced the fracture resistances and fracture patterns. Increases in cusp reduction thickness increased the mean fracture resistance
values. The teeth restored with anatomic cusp reduction
designs and reduction thicknesses of least 2.5 mm
exhibited greater fracture resistances and greater proportions of restorable fractures than the teeth subjected
to horizontal and beveled reduction designs.

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Serin Kalay et al

Corresponding author:
Dr Tugba Serin Kalay
Faculty of Dentistry, Karadeniz Technical University
61080, Trabzon
TURKEY
Email: tugbaserinkalay@hotmail.com
Acknowledgments
The authors thank Dr Tamer Tuzuner for support while preparing this study.
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

THE JOURNAL OF PROSTHETIC DENTISTRY