In vivo cusp fracture of

E. K. Hansen Department of Technology, Royal Dental College, Copenhagen, Denmark

endodontically treated premolars restored with M0D amalgam or M0D resin fillings
Hansen EK. In vivo cusp fracture of endodontically treated premolars restored with M O D amalgam or M O D resin fillings. Dent Mater 1988: 4: 169-173. Abstract - The frequency of cusp fracture of endodonticaUy treated premolars was investigated in a retrospective study. After endodontic therapy, the teeth were either restored with a M O D amalgam filling or with an enamel-bonded M O D resin filling. A very high frequency of cusp fracture was found in premolars restored with amalgam: nearly one-third fractured within 3 years after endodontic treatment. The frequency of cusp fracture differed among the 4 amalgam-restored teeth; the lower first premolar had a 15-year survival rate of 74%, in contrast to an average of 32% for the other 3 premolars. No resinrestored premolar fractured during the first 3 years, and the difference between amalgam and resin-restored teeth was highly significant at the 0-3 year interval. However, fracture of resin-restored premolars did happen in the following 3-10 year interval. From a periodontal point of view, a low frequency of cusp fracture carries great weight, and it is therefore concluded that an enamelbonded resin filling may be a treatment option much preferred to amalgam in temporarily restoring endodontically treated premolars with M O D cavities.

Key words: endodontic therapy, restorative dentistry, amalgam, enamel-bonded resin, tooth failure. E. Keith Hansen, Helsing6rsgade 7, DK-3400 Hiller6d, Denmark.

Received April 27; accepted July 24, 1987.

Endodontic therapy causes a pronounced weakening of the tooth and a consequent high risk of cusp or crown fracture. Gher et al. (1) studied the clinical features associated with tooth fracture and found that 71% of the fractured teeth had been endodontically treated. Tooth fracture is a severe problem because the fracture usually extends subgingivally and not infrequently results in loss of periodontal attachment; the fracture may even be so vertical that the tooth has to be extracted. If the tooth can be saved, the main problem for the dentist is both technical and biological in nature, i.e. the technical difficulties related to the impression-taking itself and, by impression-taking, the biological risk of further damaging the periodontal tissues (2). Even if the dentist succeeds in fabricating a welladapted restoration, the patient may face another problem. Many investigators have reported that subgingivally placed restorations always result in an inflammatory periodontal response (37). As a consequence of this, it has be12 DentalMaterials4:4. 1988

come accepted procedure to maintain restoration margins in the supragingival area whenever possible. However, in cases of cusp fracture, one nearly always has to accept a subgingival restoration margin and thereby a pronounced possibility of permanent injury to the periodontal tissues. In order to prevent tooth fracture, the optimal restoration of endodontically treated teeth is a full crown or a cast inlay that protects the cusps (8), but many dentists do not find it acceptable to fabricate the final restoration before periapical healing has been confirmed with radiographs 6-12 months later. However, one of the cusps, or the crown in whole, may actually fracture during this observation period. Still another problem is that cast restorations are expensive and quite a few patients cannot afford them. In these cases, the dentist has but two choices: amalgam or composite resin. This retrospective study was undertaken to examine whether, and to what extent, the use of an enamel-bonded restorative resin in M O D cavities of en-

dodontically treated premolars had reduced the frequency of tooth fracture when compared to endodontically treated premolars restored with a M O D amalgam filling.
Material and m e t h o d s

The material was collected from May 1986 to February 1987 from 8 dentists working as general practitioners. The data were derived from clinical examinations and review of the patients' dental records and radiographs. The limiting criteria for acceptance of data were the following: (i) an M O D cavity in an endodontically treated premolar either restored with amalgam or restored with a composite resin after previous acid-etching of the enamel; (if) no weakening of any of the cusps caused by a Class V restoration; (iii) normal occlusion and articulation; and (iv) complete permanent dentition in the anterior and pre-molar region plus at least one molar in each quadrant involved in the occlusion. The following information was recorded: name of the

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Hansen
100

individual tooth, date of endodontic therapy, restorative material, and date of control. For restorations with a composite resin: type of cavity preparation (bevel or butt-joint), use of an intermediate layer of low-viscous resin, and application technique (bulk or increment). In cases of fracture, the dentists were asked to record the date of registration of fracture, whether the fracture involved the facial cusp, the lingual cusp, or the crown as a whole, and also whether the fracture resulted in extraction of the tooth. Information was obtained on 222 endodontically treated premolars restored with either a MOD amalgam or an enamel-bonded MOD resin filling. It should be emphasized that the restorative resins in this study were applied after previous acid-etching of the enamel, but without use of a dentin-bonding agent. Trial time of the endodontically treated premolars was defined as the time elapsing between the date of endodontic therapy and (a) the date of fracture; (b) the date of last contact; (c) the date of withdrawal; or (d) the date of final registration. Total trial time was arranged into intervals of one year and, for each interval, the effective number of teeth exposed to risk of fracture was calculated. The cumulative survival rate was then calculated using life table analysis (9, 10). Analyses of differences between the cumulative survival rate of each of the 4 premolars and of differences between MOD amalgam and MOD resin restorations were tested at the 5% level of significance by means of Chi-square tests (10).

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TREATMENT

Fig. 1. Cumulative survival rate of endodontically treated premolars restored with MOD amalgam fillings. - . . . . lower first premolars; . . . . . . lower second premolars; - - = upper first premolars; . . . . upper second premolars.

a MOD amalgam or with an enamelbonded MOD resin filling.

Results
Table 1 shows the number of endodontically treated premolars restored with

Fracture pattern. Less than 10% of the fractures included the crown as a whole, i.e. usually only one of the cusps was lost. When the latter occurred, the facial cusp of the upper first premolar fractured in 52% of the cases, in contrast to 29% for the upper and lower second premolar. This difference was statistically significant at the level of p <0.05. The lower first premolar only fractured lingually. The cusp fracture nearly always ended subgingivally, and 3 of the teeth had to be extracted because of vertical root fracture. M O D amalgam. Within the first year after endodontic therapy, 13% of the premolars fractured and nearly onethird failed during the first 3 years. The cumulative survival rates for each of the 4 premolars are shown in Fig. 1; for the sake of clarity, 95% confidence intervals are omitted. The lower first premolar had the highest 15-year survival rate (74%), while the upper second premolar showed the lowest survival rate (26%). No statistically significant difference was found between the survival rates of the 2 upper premolars and that of the lower second premolar (p >0.1), while the difference between these 3 teeth and the lower first premolar was statistically significant at the level of p < 0.05.

Table 1. Number of endodontically treated premolars restored with a MOD amalgam or with an enamel-bonded MOD resin filling. Number of fractures are shown in parentheses. Tooth number* MOD restorations Amalgam 14, 24 15, 25 34, 44 35, 45 Total 48 70 13 50 (27) (45) (3) (27) Resin 23 (2) 11 (3) 2 (0) 4 (0) 40 (5)

M O D resin. The restorative resins were all chemically activated (Table 2); the "unknown" resin was assessed as being a chemically activated macrofilled composite because of the surface texture, and the fact that this restoration was made in 1974, i.e. before both microfilled, hybrid, and light-activated composites were marketed. Tooth failure was independent of the type of composite resin used (Table 2); cusp fracture was thus found with both Adaptic and Concise (macrofilled), Silar (microfilled) and P-10 (hybrid). The vast majority of the resin-restored teeth were upper premolars, among which all 5 fractures were found (Table 1). A bulk application technique was used in 4 of the 5 fractured teeth; as to the fifth fracture, no information on application technique was obtainable. Bevel preparation, both occlusally and proximally, followed by applica-

Table 2. Restorative resins used and number of fractures. Material Adaptic Concise P-10 Silar Unknown Type Number of teeth Ma Ma Hy Mi Ma 1 20 9 9 1 Fracture l 2 1 1 0

181 (102)

* = Viohl's two-digit system.

Ma = macrofilled; Mi = microfilled; Hy = hybrid.

Frequency o f cusp fracture in vivo tion of a low-viscous resin, was used in 30 of the 40 resin-restored premolars; no information on bevel/butt-joint and low-viscous resin was obtainable for the remaining 10 fillings. Four of the 5 fractures were found in teeth with beveled cavity margins. Amalgam vs. resin. As mentioned earlier, the cumulative survival rate of amalgam-restored lower first premolars was significantly higher than the survival rates of the 3 other premolars (Fig. 1). Lower first premolars are therefore not included in the statistical analysis of differences between the survival rate of M O D amalgam and M O D resin-restored teeth. A separate analysis of lower first premolars is meaningless because of the small number of observations (Table 1). The pooled cumulative survival rate of the upper first premolars, the upper second premolars and the lower second premolars is shown in Fig. 2. Chi-square analysis in a 2 x 2 contingency table requires that the expected frequency in each cell not be too small; the intervals analyzed were therefore restricted to 0-3 years, 3-6 years, and 6--10 years. Analysis beyond 10 years was not made because only 8 resin restorations were older than 10 years, and only 4 restorations were older than 11 years. The analysis (Table 3) showed a highly significant difference between the survival rate of amalgam and resin-restored premolars at p <0.001; the main reason was that no resin-restored tooth fractured during the first 3 years. The resin-restored premolars had a slightly better survival rate during the 3~5 and 6-10 year intervals (Fig. 2; Table 3), but this difference was not statistically significant (p >0.05).
Discussion

171

Like all retrospective studies, this in-

vestigation has an inherent disadvantage in that the data obtained from review of the patients' records only partially answered the questions asked. Many essential details may be lost in a retrospective study because most patient records do not contain all the information needed for a careful investigation. This problem does not prevent a discussion of the possible causes of the different survival rates of amalgam and resin-restored premolars, but the results of this study should be cautiously interpreted, especially since the number of resin-restored teeth was rather small. Laboratory studies have shown that a non-bonded intracoronal restoration does not strengthen the tooth, and that the fracture resistance of premolars with M O D cavities restored with amalgam or with a non-bonded composite resin is similar to that of premolars with an unfilled M O D cavity (8, 11, 12). Several authors have published papers on the reinforcing effect of an enamelbonded composite restoration without previous application of a dentin-bonding agent, as investigated in the present study, but the results are contradictory. Reel & Mitchell (13), Eakle (14) and Stampalia et al. (15) did not find a significant increase in the fracture resistance, in contrast with Simonsen et al, (11), Douglas (12) and Mackenzie (16), who all found that premolars with enamel-bonded composite restorations were stronger than those either restored with amalgam or left unrestored. However, methods used in vitro to measure the fracture resistance of teeth with an M O D preparation may not reproduce what actually happens in vivo. In the present investigation only 3 of the 107 fractures were so vertical that the tooth had to be extracted. This low frequency of vertical fracture is not in accordance with the in vitro results presented by Stampalia et al. (15); these authors found that all except one of 22

fractures occurred as a middle split of the tooth through the pulpal floor of the cavity preparation. The discrepancy between the results of the present study and the results published by Stampalia et al. (15) may very well be caused by the different dimensions of the M O D cavities. A further possible explanation has been given by Craig (17), who pointed out that in vitro testing of a rigidly supported tooth ignores the resiliency of the periodontal ligament. Also, it does not seem very likely, considering the complex occlusal function, that in vivo loading of the cusps can be completely reproduced in vitro with the test methods used (11-16). The most astonishing finding in the present study Was the very high frequency of cusp fracture of the amalgam-restored premolars, where nearly one-third fractured within 3 years after endodontic treatment (Table 3). These fractures, most often subgingival, may result in permanent injury to the periodontal tissues not only because of the fracture itself, but also because even a well-adapted restoration will hardly ever be surrounded by the same healthy periodontal tissues as the natural tooth surface itself (3-7). The frequency of fracture differed among the 4 amalgam-restored premolars (Fig. 1). The high 15-year survival rate of the lower first premolar (74%) compared to an average of 32% for the other three premolars (Figs. 1 and 2) is probably related to both the anatomical form and the location of the tooth. As to the latter, Leinfelder (18) has presented a wear factor of composite resin as a function of location: the lower first premolar was given a wear factor of 1 x , the upper first premolar 3 x , and the two second premolars 4 x . These wear factors, being a function of location, are in fairly good agreement with the different frequencies of cusp fracture of the 4 premolars found in the present study (Fig. 1).

Table 3. Chi-square analysis of survival rates (cusp/crown fracture) of endodontically treated permolars restored with MOD amalgam fillings or with enamel-bonded MOD resin fillings. Years after treatment 1~ 0-3 3-6 6-10 Total Chi-square 168 106 78 MOD amalgam restorations dx 53 17 19 Ux 9 11 9 l'x 163.5 100.5 73.5 l'~-d~ 110.5 83.5 54.5 lx 38 37 29 MOD resin restorations d~ 0 3 2 u~ 1 5 19 1'~ 37.5 34.5 19.5 l'x-d~ 37.5 31.5 17.5 ;(2 16.509 1.375 2.144 20.028

1 = intact at beginning of interval; dx = faillures during interval; ux = withdrawn and lost cases during interval; 1'x = effective numbers exposed to risk of fracture. 12"

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Hansen

100

80
ILl tY <

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W >

~ 40
< IE

20

10

12

14

YEARS AFTER TREATMENT

Fig. 2. Pooled cumulative survival rate of endodontically treated upper first premolars, up-

per second premolars and lower second premolars. 9 = MOD amalgam restorations; o = enamel-bonded MOD resin restorations. Vertical bar = 95% confidence interval.

The frequency of facial cusp fracture of the upper first premolars (52%), compared with 29% for the upper and lower second premolars, may be related to the anatomical form of both the pulp chamber and the cusps (19). The difference between the height of the 2 cusps is more pronounced in the upper first than in the upper second premolar, and the occlusal slope of the facial cusp is more steep (19), rendering the facial cusp of the upper first premolar more susceptible to fracture than the lingual cusp. As to the 2 lower premolars, endodontic therapy will most often result in a weak lingual cusp. Another interesting fact arises from Fig. 2, which shows the cumulative survival rates of amalgam and of resinrestored premolars. The 3-year survival rate of resin-restored teeth was markedly better that that of the amalgamrestored teeth. The difference between the short-term survival rate of amalgam and of resin-restored premolars can be illustrated by the fact that this difference would still have been statistically significant (p = 0.02) even if 5 of the 38 resin-restored teeth had fractured during the first 3 years after endodontic treatment. After 3 years, cusp fracture of resinrestored premolars happened with nearly the same frequency as amalgamrestored teeth. The combined use of

bevel and a low-viscous resin could not prevent tooth failure. This confirms the in vitro results published by Reel & Mitchell (13) and by Douglas (12), who did not find a significant difference between the fracture resistance of MOD cavities with beveled or with butt-joint cavity margins. There are 2 more variables in the present study which should be discussed, i.e. the application technique and the fact that the restorative resins were used without a dentin-bonding agent. As to the application technique, no information was obtainable on one of the 5 fractures; the other 4 failures were found in premolars where the restorative resin had been applied with a bulk technique. In this context it is interesting that the polymerization contraction of bulk-applied restorative resins in MOD cavities causes a deformation of the cusps (20-22). The fractures found in the resin-restored premolars may have been initiated by an incomplete cusp fracture caused by the stresses induced in the enamel during the polymerization contraction of the restorative resin. A possible solution to this problem may be to use an oblique incremental technique, which reduces the wall-to-wall polymerization contraction (23) and thereby the cuspal deformation (21, 22).

No dentin-bonding agent was used in the resin-restored premolars and it is thus possible that the fracture resistance could have been increased. However, the in vitro results published on the effect of these bonding agents are contradictory: Douglas (12) and Eakle (14) found that a dentin-bonding agent increased the fracture resistance of MOD-prepared premolars, while Reel & Mitchell (13) did not find a significant improvement. Also, no commercial dentin-bonding agent is as yet strong enough to totally prevent the formation of a contraction gap (24). Furthermore, even strong bonding agents have only a mediocre effect on the high-viscous composites intended for use in posterior teeth (25). Thus, it is possible, but not evident, that the frequency of cusp fracture found in the present study could have been reduced had a dentin-bonding agent been applied. In conclusion, the possibility of using enamel-bonded composites as temporary restorations for endodontically treated premolars should be Considered. There are, of course, still many unsolved problems with regard to the use of composite resins in posterior teeth and especially in large MOD cavities; wear resistance and marginal leakage, just to mention two of the problems. However, from a periodontal point of view, the low frequency of cusp fracture carries great weight.
Acknowledgement - This paper was sup-

ported in part by the Research Foundation of the Danish Dental Association.

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