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journal of dentistry 39 (2011) 527535

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Fracture strength and fracture patterns of root lled teeth restored with direct resin restorations
N.A. Taha a,b,*, J.E. Palamara a, H.H. Messer a
Melbourne Dental School, University of Melbourne, Melbourne, Australia Department of Conservative Dentistry, Jordan University of Science and Technology, Conservative Dentistry Department, PO Box 3864, Irbid 21110, Jordan
b a

article info
Article history: Received 19 February 2011 Received in revised form 10 May 2011 Accepted 11 May 2011

abstract
Objective: To compare fracture characteristics of root-lled teeth with variable cavity design and resin composite restoration. Methods: 80 extracted intact maxillary premolars were divided randomly into eight groups; (1) intact teeth; (2) unrestored MOD cavity; (3) unrestored MOD cavity plus endodontic access through the occlusal oor; (4) unrestored MOD plus endodontic access with axial walls removed; (5) MOD restored with resin composite; (6) MOD plus endodontic access, resin composite; (7) MOD plus extensive endodontic access, resin composite; (8) MOD plus

Keywords: Root lled teeth Resin composites Fracture strength Fracture pattern

extensive endodontic access, GIC core and resin composite. A ramped oblique load was applied to the buccal cusp in a servohydraulic testing machine. Fracture load and fracture patterns were recorded. Fracture loads were compared statistically using 1-way ANOVA, with Dunnett test for multiple comparisons. Results: Unrestored teeth became progressively weaker with more extensive preparations. Endodontic access conned within the occlusal oor did not signicantly affect strength compared to an MOD cavity. Loss of axial walls weakened teeth considerably [292 + 80 N vs 747 + 130 N for intact teeth]. Restoration increased the strength of prepared teeth particularly in teeth without axial walls. Teeth with a GIC core were not signicantly weaker than intact teeth [560 + 167 N]. Failures were mostly adhesive at the buccal interface, with the fracture propagating from the buccal line angle of the occlusal oor (MOD and MOD plus access groups) or of the proximal box (axial wall removed). Conclusions: Direct restorations increased fracture resistance of root lled teeth with extensive endodontic access. Both restored and unrestored teeth showed similar fracture patterns. # 2011 Elsevier Ltd. All rights reserved.

1.

Introduction

Direct tooth-coloured restorations are often used for rootlled teeth as a relatively low cost, aesthetic alternative to cuspal coverage restorations. Historically, both amalgam and resin composite restorations have been widely used even for

posterior teeth,1,2 with composite resin direct restorations showing good long term outcomes. More recent studies3,4 have indicated less favourable but still reasonably high survival of teeth with direct restorations, and the prospective studies of Mannocci et al.5,6 indicate good outcomes with both amalgam and resin composite restorations (plus a prefabricated post) over the medium term (3 years). Clearly the choice

* Corresponding author at: Department of Conservative Dentistry, Jordan University of Science and Technology, Conservative Dentistry Department, PO Box 3864, Irbid 21110, Jordan. Tel.: +962 776566110; fax: +962 2 7258907. E-mail addresses: n.taha@just.edu.jo, nessrin_taha@yahoo.com (N.A. Taha). 0300-5712/$ see front matter # 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jdent.2011.05.003

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of restoration will depend on remaining tooth structure, with direct restorations limited to teeth with substantial coronal dentine. In addition to aesthetic considerations, an acceptable restoration must restore function and preserve the remaining tooth structure against fracture. Root-lled teeth are at increased risk of fracture. Caries and excessive removal of dentine during root canal treatment, rather than low moisture content and increased brittleness7,8 reduce tooth strength. Endodontic procedures reduce tooth strength modestly compared to extensive cavity preparations,9 but only as long as the endodontic access is conned to the occlusal oor of the cavity. Loss of axial dentine walls, which is common in teeth requiring root lling, greatly weakens teeth.8 Resin composite restorations have the advantage of bonding to tooth structure, which might strengthen the tooth and offer an alternative restorative technique to cuspal coverage. However, polymerization shrinkage is a serious drawback of these materials, resulting in cuspal strains with subsequent stress or disruption of the bond, microleakage and recurrent caries. Attempts at minimizing this problem have included the use of low shrink composites,10 incremental placement11 and the use of liners including glass ionomer, owable composites and polyacid-modied resin composites.1214 The performance of direct resin composites for the restoration of root lled teeth has been investigated experimentally ever since posterior resin composite materials were rst introduced1517 and clinically in both retrospective and prospective clinical studies. Despite the less favourable outcomes in comparison with cuspal coverage restorations reported in retrospective studies,3,4 two randomised clinical trials found superior performance compared to amalgam restorations in terms of fracture resistance, but with a problem of recurrent caries. Similar survival to full coronal coverage was observed over a three year period.5,6 In experimental studies, fracture resistance to static loading has been used as a measure of the effect of cavity preparation and/or restoration on tooth strength. Although the fracture load is typically much higher than functional occlusal loads, it is still a valid method for comparing restorative materials and different cavity designs. Adhesive resin composite restorations have been reported to increase the fracture resistance of root lled teeth compared to non adhesive llings.1822 Fibre reinforced resin composite has also been studied as a conservative restoration, but was not found to improve the fracture strength compared to conventional resin composite.23 Different bonding systems18 and base materials including glass ionomer cement (GIC) and composites24 have also been investigated for their effect on fracture strength. This experimental study was conducted to compare the fracture resistance of extracted root lled maxillary premolars with variable cavity design and direct restoration techniques using resin composite. In a previous study,25 preserving the proximal dentine walls of an endodontic access cavity and placement of a glass ionomer base beneath the resin composite restoration of root lled maxillary premolars signicantly reduced cuspal deection and microleakage but did not affect the strains within cusps. The null hypothesis of this study is that preserving the proximal dentine and

placement of a GIC base will improve the fracture strength and result in a more favourable fracture pattern of root lled maxillary premolars restored with direct resin composites.

2.

Materials and methods

Overview: Three different cavity preparations were tested: MOD, MOD plus endodontic access conned to the occlusal oor of the MOD cavity, and MOD plus extensive endodontic access with the axial walls removed between the proximal boxes and access preparation (Fig. 1). Teeth were then restored with direct resin composite material, plus an additional group in which a GIC core was placed in teeth with the extensive endodontic access before placing resin composite. All teeth were then subjected to an oblique load of 458 to the vertical on the buccal cusp until fracture. Tooth selection and mounting: Eighty intact, non carious maxillary premolars were used in this study. Teeth of similar size were selected by measuring the buccolingual width in millimetres using a digital calliper and allowing a maximum deviation of 10% from the determined mean.25 The teeth were then randomly assigned into eight groups (n = 10). The project was approved by the Ethics in Human Research Committee of the University of Melbourne. Teeth were stored in 1% chloramine T solution in distilled water (pH = 7.8) (Sigma Aldrich Co., St. Louis, MO, USA) for two weeks. Teeth were mounted vertically in dental stone within nylon mounting rings.9,25,26 Dental stone covered the roots to within 2 mm of the cementoenamel junction (CEJ), to approximate the support of alveolar bone in a healthy tooth. Cavity preparations: The teeth were prepared as follows. Group 1: Intact teeth (control). Group 2: A standardized MOD cavity was prepared using a tungsten carbide round-ended ssure bur (Komet H21R, Brasseler, Lemgo, Germany) in a high speed handpiece with water coolant so that the bucco-lingual width of the occlusal isthmus was one third of the width between buccal and lingual cusp tips, and the buccolingual width of the proximal box was one third of the bucco-lingual width of the crown. The gingival oor of the box was 1 mm coronal to the cementoenamel junction; occlusal depth was 3.0 mm and the total depth 5 6 mm (Fig. 1). The cavosurface margins were prepared at 908 and all internal angles were rounded. Consistency in cavity preparation was ensured by parallel preparation of the facial and palatal walls of the cavity. Group 3: An MOD cavity was prepared similarly to group 2, then an endodontic access cavity conned within the occlusal oor was cut leaving the proximal dentine walls intact. Root canals were prepared using the ProTaper rotary nickel titanium system (Dentsply, Maillefer, Ballaigues, Switzerland) and lled by cold lateral condensation using gutta percha and AH Plus root canal sealer (Dentsply, Maillefer Detrey, Konstanz, Germany). Gutta percha was removed to 2 mm below the CEJ. Excess sealer was removed with a cotton pellet moistened with alcohol. Group 4: Teeth were prepared similarly to group 3, but the endodontic access included the removal of all dentine between the proximal box and the pulp chamber. Root canals were prepared and obturated similarly to group 3.

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Fig. 1 Diagram of cavity preparations and direction of fractures in the prepared unrestored teeth. The basic preparation was an MOD cavity with the following dimensions: occlusal depth of 3 mm, isthmus width of 1/3 inter-cuspal distance, and proximally to 1 mm above the CEJ. The endodontic access was either confined to the floor of the pulp chamber with axial walls (orange) intact or with the walls removed. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of the article.)

Restoration: Group 5 (MOD cavity): The entire cavity preparation was etched with 37% phosphoric acid (Super Etch, SDI Limited, Bayswater, Australia; batch no. 030648) for 20 s, rinsed with airwater spray for 10 s and dried for 20 s. A bonding agent (AdperTM Single Bond, 3 M ESPE, St Paul, USA, lot no. 184141) was applied and light cured for 20 s, and the cavity was incrementally restored with OD3 shade resin composite (Glacier, SDI Limited, Australia, batch no. 050489). Three increments were placed and cured using a LED light curing source (Bluephase C8, CE Ivoclar, Vivadent AG, F1-9494 Schaan, Liechtenstien) at an intensity of 800 mW/cm2 for 40 s. Group 6 (MOD plus endodontic access): The cavity was restored with resin composite, as in group 5. The rst increment was packed into the canal orices and covered the proximal boxes to the level of the occlusal oor. The last two increments covered the entire mesiodistal and buccolingual width of the cavity. Group 7 (MOD plus extensive endodontic access, resin composite restoration): A similar restoration to group 6 was placed. The rst increment was packed into canal orices and both proximal boxes to a depth of approximately 1 mm. Group 8 (MOD plus extensive endodontic access, GIC core and resin composite): Prior to restoration with composite a 10% polyacrylic acid dentine conditioner was applied for 10 s and a glass ionomer base (Fuji VII, lot # 0609270. GC Corporation, Tokyo, Japan) was placed above the gutta-percha to reproduce the oor of an MOD cavity. The teeth were then restored with resin composite as above. After restoration teeth were stored in an incubator at 378 C in 100% humidity for 24 h before testing. Teeth were subjected to a 45 degree oblique compressive load applied to the palatal incline of the buccal cusp, at a crosshead speed of 0.5 mm/min in a servohydraulic material

Fig. 2 Experimental setup of a tooth in the testing machine, with a round-ended steel cylinder of 1.3 mm radius applied to the palatal incline of the buccal cusp at an angle of 458 to the vertical.

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an MOD cavity (541 186 N) and teeth without axial walls and restored with a GIC core (560 167 N) were not signicantly weaker than intact teeth (747 130 N). Teeth restored with resin composite only were weaker than intact teeth (451 206 N, p = 0.028 when axial walls were present; 449 102, p = 0.001 when axial walls were not present).

3.3.

Fracture patterns

Fig. 3 Box plot of the effect of cavity preparation on fracture strength of unrestored teeth.

test system (MTS model 801, MTS Corporation, Minneapolis, USA) using a round-ended steel cylinder of 1.3 mm radius (Fig. 2). The force required to fracture the tooth was recorded in Newtons. Data analysis: Data were analysed using one way ANOVA followed by the Dunnett T3 test for multiple comparisons, at the 5% signicance level. Fracture patterns were evaluated under a stereomicroscope and categorized according to location, the restoration tooth interface where fracture occurred, the point of initiation of the fracture and the severity of the fracture. Mode of failure (adhesive, cohesive, mixed) was assessed using standard criteria20,27 at a magnication of 20. Representative samples were also gold sputtered for studying the fracture surface under the scanning electron microscope (SEM) at magnication of 200.

Intact teeth fractured consistently within the buccal cusp (Table 1 and Fig. 5). Most fractures (7/10) were above the CEJ, whilst 3/10 were below the CEJ, with only one subcrestal. Unrestored teeth with cavity preparations demonstrated consistent patterns of fracture of the buccal cusp, extending subcrestally. In the MOD and MOD plus endodontic access groups, the crack initiated at the buccal line angle of the occlusal oor (Fig. 5), except for one tooth in the latter group where the crack initiated in the mid-oor region. In teeth with the axial walls removed, the fracture initiated at the buccal proximal line angle. All cracks propagated obliquely to the buccal root surface. Restored teeth also failed in consistent patterns within each group. Other than 2/10 fractures within the buccal cusp in the MOD group, failure was predominantly adhesive between restorative material and tooth structure, when observed at the light microscopic level and conrmed with SEM of representative samples (Fig. 6). Debonding of the restoration was predominantly at the buccal interface with the cavity wall (Fig. 7), with at most 2/10 teeth per group debonding at the palatal interface. As in the unrestored teeth, the crack initiated at the buccal line angle of the cavity preparation, either at the occlusal oor (MOD and MOD plus access groups) or at the oor of the proximal box (teeth with the axial wall removed). The fractures extended obliquely to the buccal surface and were mostly subcrestal except in the restored MOD group where 3/ 10 were supracrestal.

Fracture Load (Newtons)

900 800 700 600 500 400 300 200 100 0


Restored Unrestored

3.
3.1.

Results
Unrestored teeth

Intact teeth fractured at a load of 747 130 N (Fig. 3). Teeth became progressively weaker with more extensive cavity preparations. MOD cavity preparation reduced fracture strength by 37.5% (467 141 N, p = 0.001 compared with intact teeth). Endodontic access conned within the occlusal oor did not further reduce strength compared to an MOD cavity (442 132 N, p = 0.99 compared with MOD). Removal of axial walls further weakened teeth considerably (mean load at fracture 292 80 N, only 39.1% of intact teeth).

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M O D

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po

ta

Ac ce

In

om

l+

Group

3.2.

Restored teeth

Restoration increased the strength of prepared teeth, but the increase was signicant only in preparations involving loss of axial walls (Fig. 4). Following restoration, teeth with

Fig. 4 Stacked bar graph of the effect of restoration on fracture strength of the prepared teeth. The lower part of each bar is the mean fracture load for unrestored cavity preparations, whilst the upper bar is the mean load following restoration. Standard error bars apply to the mean for restored teeth.

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Table 1 Fracture patterns for unrestored and restored teeth. Group/procedure Level Supracrestal
Group 1: intact teeth Unrestored cavity preparations Group 2: MOD cavity Group 3: MOD + endo access Group 4: MOD, no axial walls Restored teeth Group 5: MOD, composite Group 6: access + composite Group 7: no axial walls, composite Group 8: no axial walls, GIC liner 9 0 0 0 3 0 0 1

Pattern Subcrestal
1 10 10 10 7 10 10 9

Margin Other
0 0 1 0 0 1 0 0

Within cusp
10 0 0 0 2 0 0 1

From line angle


10 9 10 8 9 10 9

Buccal
10 8 8 7

Palatal
0 2 2 2

Margin: the cavity margin (either buccal or palatal) at which debonding between the restoration and tooth structure occurred (see Fig. 7). From line angle: fracture propagated from either the buccalocclusal or the buccalproximal line angle, obliquely towards the buccal root surface (see Fig. 7). Other indicates a more complex fracture pattern.

Fig. 5 Side view of fracture patterns of intact and unrestored teeth. (A) Intact tooth, fracture within buccal cusp; (B) MOD cavity, subcrestal fracture beginning from buccal line angle of the occlusal floor; (C) MOD plus endodontic access, same pattern as B; (D) axial walls removed, subcrestal fracture initiated at buccal proximal line angle.

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4.

Discussion

Fig. 6 A scanning electron microscope view of the fracture surface at 200T magnification, showing predominantly adhesive failure at the interface with dentine with some areas of localized cohesive failure within enamel.

Methods: Despite its limitations, fracture testing remains a common experimental method of evaluating restorative procedures for root lled teeth. Reeh et al. highlighted the shortcomings of destructive methods of testing, which include the non-physiologic loads required to cause fracture, the variation amongst teeth used in experimental studies, and differences in test conditions leading to fracture.17 Differences in tooth morphology (such as the difference in cross-sectional shape of the cervical area between rst and second premolars) may also inuence fracture susceptibility and patterns. However, highly consistent fracture patterns were observed in this study despite the inclusion of both rst and second premolars. The direction and location of the applied load and the shape of the loading tip may all inuence results, and the results should be extrapolated to clinical patterns of failure with some degree of caution. Before proceeding with testing of the eight experimental groups, additional groups were prepared and tested for the effect of periodontal ligament simulation and thermal cycling on fracture strength. Fracture load was unaffected by either thermal cycling or the presence of a simulated periodontal ligament as has also been previously reported,28,29 and therefore neither was included in the main study. The

Fig. 7 Front and side view of fracture patterns of restored teeth with a schematic illustration of the initiation and extension of the line of fracture. Failures were predominantly adhesive at the buccal interface. The crack propagated from the buccal line angle at the occlusal floor (MOD plus access groups) (AC) or at the floor of the proximal box for teeth with the axial wall removed (DF).

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embedding material should ideally simulate the capacity of bone to absorb masticatory load and therefore withstand the load applied in mechanical testing. However there is no consensus on the material that should be used and it varies greatly amongst studies: acrylic resin19,22,30 or polystyrene resin20,27 and die stone.21,31 In the present study, an oblique load (458 to the long axis of the tooth) was applied to the occlusal incline of the buccal cusp using a rounded loading tip, which contacted the enamel surface away from the restoration margin. This pattern of loading was intended to simulate normal working side occlusal contacts. In previous studies, the direction of the applied load has included axial loading on both buccal and palatal cusps16,17,32 or at 308 to the vertical on the buccal cusp incline,27 or at the tooth-restoration interface.15,18,22 Cavity preparations: Since the early work of Vale,33 numerous authors have documented the weakening effect of cavity preparations on tooth strength and fracture resistance, although relatively few have investigated the effect of endodontic procedures. Reeh et al. using non-destructive strain measurements, reported that endodontic access had little effect (5%) on cuspal stiffness compared with an MOD cavity preparation (63% reduction relative to intact teeth).9 In that study, however, endodontic access was conned to the occlusal oor of the cavity preparation. In contrast, cuspal stiffness was markedly reduced when endodontic access included removal of the axial walls of dentine adjacent to each proximal box.26 In this study, endodontic access conned to the occlusal oor also had minimal impact on fracture resistance (3%) but loss of axial walls reduced fracture strength by more than 60% relative to intact teeth. These results are very similar to other fracture studies16,32 despite differences in cavity preparations and in the type and location of loading. Extensive cavity preparation and endodontic access clearly cause a major reduction in fracture resistance, regardless of how it is measured. Hood proposed a cantilever beam hypothesis to explain loss of fracture resistance. According to this hypothesis, cusps of teeth with MOD cavity preparations function as a cantilever beam, with the extent of deection under load inuenced by both beam thickness and length (to the third power).34 Hence a deeper, wider cavity will result in substantially greater cusp deection for a given load, with the cavity oor serving as the fulcrum for bending. The buccalocclusal line angle thus becomes the site of fracture initiation. When the endodontic access is conned within the occlusal cavity oor, the fracture occurs at a much higher point (the occlusal oor) than when the axial walls are removed (buccal proximal line angle). This concept has been previously conrmed in molars26 and is clearly illustrated in this study (Fig. 4) showing the deeper location of fracture initiation with loss of the axial walls of the proximal box. Based on the remaining cusp thickness after the MOD preparation it was not judged necessary to place an intracanal post. Several studies have found a reinforcing effect of placement of bre or titanium posts in addition to direct resin composite restorations, without negatively affecting the fracture pattern.19,35,36 A retrospective clinical study reported a survival rate of root lled teeth restored with either a prefabricated post or a cast post to be 83% over a 10 year

period.37 On the other hand placement of a bre post with or without cusp capping with resin composite did not result in additional benet compared to composite resin restoration without post and cusp capping.38 One study27 found that glass bre posts reduced fracture resistance of root lled teeth with moderate tooth structure loss and did not restore the fracture resistance of teeth with major loss of tooth structure. Restorations: Restoration with resin composite generally increased fracture strength relative to the unrestored teeth, though not always to a statistically signicant level. Two of the four restored groups were not signicantly weaker than intact teeth. As in many similar studies, the variation within groups was large, making it difcult to achieve statistical signicance. Most previous studies have similarly demonstrated a strengthening effect of resin composite restorations compared to unrestored teeth with similar cavity preparations,16,17,32,39 but achieving comparable strength to intact teeth has been more variable. Soares et al.20 found that none of the restorative techniques employed recovered strength to levels of sound nonrestored teeth, and MOD cavities restored with resin composite placed with direct technique (similar to our study) were stronger than those restored with laboratory processed resin and indirect technique. This was attributed to more conservative cavity preparation with the direct technique. Several dentine bonding systems have been developed to improve the bond strength of composite resin to tooth structure. Generally dentine bonding systems are reported to increase fracture resistance.18,22 Siso et al.19 found a total etch two step adhesive more effective in increasing the fracture strength than a one step adhesive which is similar to ndings by others.21,22 The use of two step adhesive systems (as used in this study) is still a common practice amongst clinicians and in experimental studies.19,20,38 The use of glass ionomer under resin composite restorations has been recommended to improve marginal adaptation.25,40 Despite the lower mechanical properties compared to resin composites, placement of a glass ionomer liner in this study did not negatively affect the fracture strength. Similar to ndings of other studies16,18 it improved fracture strength of the restored teeth to levels not signicantly different from the intact tooth. This could be related to the ability of glass ionomer to bond to dentine and act as absorber for strains encountered during polymerization shrinkage and mastication by virtue of its intrinsic porosity.41,42 It should be noted, however, that the standard deviation for this group was large, and fracture strength was not signicantly greater than in the group restored with resin composite alone. The patterns of fracture of restored teeth were very consistent in this study, closely following the patterns for unrestored teeth with similar cavity preparations. Failure typically occurred by debonding at the buccal interface, with cuspal fracture extending obliquely from the buccal line angle of the oor of the cavity preparation (Fig. 5). Depending on the extent of the endodontic access, the fracture occurred from the occlusal oor of the MOD preparation or more deeply from the buccal proximal line angle. The similarity in fracture patterns between unrestored and restored teeth suggests that failure occurs in two stages: rstly, debonding occurs at the buccal interface between the restoration and cavity wall.

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Following debonding, the buccal cusp behaves as a cantilever beam as in the unrestored tooth, and fractures in the same manner. Fracture patterns have varied widely in experimental studies, which can be attributed only in part to loading conditions. With vertical loading applied equally to cuspal inclines of both buccal and palatal cusps,9,20,32 fracture was predominantly vertically through the restoration and the middle of the proximal box, extending into the root. This pattern occurred in teeth with direct bonded restorations, but marginal failure with cuspal fracture was also seen,20 Despite similar loading conditions, others have reported that fracture always occurred at the restorationtooth interface and never within the restorative material itself.16,21 Oblique loading typically involves adhesive failure at the toothrestoration interface (15,16,18, this study). On the other hand loading crowned teeth was reported to cause cohesive failure within the veneer with fracture initiating at the contact area regardless of the loaded cusp.43 Clinical implications: Preservation of all remaining sound coronal dentine should be a primary objective in prevention of fractures of root lled teeth. A conservative endodontic access which preserves the axial dentine is recommended whenever possible, but is often precluded by the extent of previous caries and restorations. In terms of fracture resistance, resin composite restoration provides some strengthening effect, but based on previous experimental and retrospective clinical studies does not provide the same degree of long term protection as cusp coverage restorations.2,44 Perhaps direct restoration should be considered a valid interim restoration for root lled teeth before cuspal coverage can be provided. However teeth should be continuously monitored for the risk of recurrent caries.6,45

5.

Conclusion

Endodontic access with loss of axial walls weakened teeth by 60% compared to intact teeth. Direct resin composite restoration signicantly increased fracture resistance of these teeth, with a GIC core resulting in fracture strength similar to that of intact teeth.

Acknowledgment
We would like to thank Mr. Geoff Adams from Melbourne Dental School, University of Melbourne for his assistance in the statistical analysis.

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