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Fracture Resistance of endodontically treated teeth restored with custom cast

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different cements; In vitro stud...

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ENDODONTOLOGY Original Research

Fracture resistance of endodontically treated teeth restored

with custom cast post core using non uniform and uniform
ferrule length luted with two different cements: In vitro
study.

MOKSHA NAYAK * #
KRISHNA PRASADA ** #
DHEERAJ SHETTY *** ##

ABSTRACT
Post and core are a commonly accepted time honored method for restoring endodontically treated teeth. The
present consensus regarding post is to provide retention of the core rather than reinforcement of the tooth. The
purpose of the study was to evaluate & compare in vitro the fracture resistance of endodontically treated teeth
restored with custom cast post core using non uniform and uniform ferrule length luted using zinc phosphate &
resin cement.
A total of 60 human single rooted maxillary central incisors were endodontically treated and restored with custom
cast gold post core and were randomly assigned to 6 groups of 10 teeth each having the following features.
Uniform ferrule (2 mm buccal, lingual & 2 mm proximal) were placed in group 1 and 3, non uniform ferrule ( 2
mm buccal, lingual and 0.5 mm proximal) were placed in group 2and 4,no ferrule were given for group 5 and 6.
Post and cores for group 1,2 and 5 were luted with zinc phosphate cement and group 3,4and 6 were luted with
Resin cement. Fracture resistance of the entire specimen group was measured using INSTRON testing machine
and the data obtained was statistically analyzed.
The gold cast post core using 2mm uniform ferrule luted with Resin cement showed highest fracture resistance
compared to all the groups.
Key Words: post & core, resin cement, zinc phosphate

INTRODUCTION preparation. Conversely it has been shown that

The restoration of endodontically treated teeth
has become a great challenge to restorative dentistry
since effectiveness and predictability of endodontic
therapy has increased. The failure of majority of
1
restored pulpless teeth is due to substantially
decreased structural integrity of tooth because of
the removal of tooth structure during endodontic
access, dowel space preparation & cavity
providing coronal coverage significantly increased
the stiffness of remaining tooth.2 A dowel and core
is often indicated for retention and reinforcement
of final restoration.3 However in-vitro and in-vivo
research has demonstrated that a dowel does not
reinforce the endodontically treated teeth.4 A cast
post is especially indicated when the loss of dental
substance is sufficiently significant to need

* Principal & Head of the Department, ** Professor, *** Senior Lecturer, # Department of Conservative Dentistry and Endodontics, KVG Dental College, Sullia.
## Department of Conservative Dentistry and Endodontics, New Horizon Dental College, Sakri, Bilaspur, Chattisghar.

80
ENDODONTOLOGY
maximum retention for coronal reconstruction
especially in non circular canals . Cast post core
5
closely reproduces morphology of root canal space
and may be more conservative option with minimal
dentin removal. Preference of the cast post core
5
system is derived in part from incorporation of
encircling collar of metal (ferrule) hypothesized to
protect the tooth from wedging stresses. ' A key
1
element of tooth preparation when using a post and
core is incorporation of a ferrule.
The word ferrule originates from Latin for iron
(ferrum) and bracelets (variola), which is an
encircling band of cast metal around the coronal
surface of the tooth providing protective
reinforcement to endodontically treated teeth. 7
According to Eissmann; ferrule should be of
minimum of 2 mm for a protective effect. To
achieve optimal results the material used for post
should have physical properties similar to that of
dentin and be biocompatible in oral environment.
Retention of post core is vital for long term success
of final restoration. Zinc phosphate has been the
gold standard for post cementation.’ The traditional
cements produce only motional resistance,
Table 1-Study Materials
SI. NO MATERIAL MANUFACTURER
1 Type 11 gold alloy
2 RelyX ARC resin cement 3 M Dental products
3 Zinc phosphate cement HARVARD Germany
4 INLAY WAX medium
MOKSHA NAYAK, KRISHNA PRASADA, DHEERAJ SHETTY
however newer dual cure adhesive resin & bonding
agents have been introduced which have showed
good adhesion to tooth structure & provide
interradicular reinforcement of roots within the thin
walls of dentin.8 The present study was undertaken
to compare in vitro the fracture resistance of
endodontically treated teeth restored with custom
east post and core with uniform and non uniform
ferrule length luted using Zinc phosphate cement
and resin cement.
MATERIALS AND METHODS
60 human single rooted maxillary central
incisors extracted for routine clinical reasons were
used for the study. The teeth were selected such
that they have root length of atleast 13mm (14+1)
and almost similar bucco-lingual dimensions. They
were examined under 20 x magnifications under
microscope to rule out any cracks, caries craze
lines. The teeth were also radiographed to
determine the presence of a single canal. Teeth with
more than one canal, immature root apices, and
canals involving the root, teeth with craze lines or
fracture and those with root length less than 13mm
or thin curved roots were excluded.
COMPOSITION
18 karat gold
Methyl metacrylate, TEG0MA, Bis- GMA,
Zirconia fillers, photoinitiators
Powder: 90 % zinc oxide
Liquid:
69% buffered phosphoric acid
Aluniniumphosphate, aluminium, zinc
GC ASIA
81
ENDODONTOLOGY
USING NON UNIFORM AND UNIFORM FERRULE LENGTH LUTED WITH TWO DIFFERENT CEMENTS: IN-VITRO STUDY.
The six groups of teeth were subjected to
standard endodontic treatment. The teeth were
sectioned horizontally 3 mm above cemento
enamel junction with diamond disc. The post space
preparation was done with removal of guttapercha
using heated plugger followed by canal
enlargement using peaso reamer (No 3) preserving
4 mm of apical guttapercha. Post space obtained is
parallel with tapered end. The teeth were mounted
in acrylic resin block with long axis of each tooth
parallel to long axis of block and the mid facial
extent of Cemento enamel junction located 2 mm
coronal to resin block. Tooth reduction for crown
preparation was performed to standardized
specifications. The crown margins were designed
to follow the simulated contours of free gingival
tissue with facial and lingual extent more apical
compared to proximal margins. The margins were
made 1,5 mm wide on the facial & proximal aspect
with round shoulder configuration using diamond
rotary instrument. Tooth reduction of each tooth
was standardized to 1.5 mm on facial aspect
and’0.5 mm on lingual aspect. The preparation
convergence angle was standardized using
handpiece mounted on a dental surveyor
Specimens divided in 6 groups
FRACTURE RESISTANCE OF ENDODONTICALLY TREATED TEETH RESTORED WITH CUSTOM CAST POST CORE
Grouping of specimens
All the teeth were endodontically treated and
then restored with custom east gold post core and
were randomly assigned to 6 groups of 10 teeth
each.
GROUP I: Uniform ferrule (2 mm buccal,
lingual & 2 mm proximal) luted with zinc
phosphate cement.
GROUP 2: Non uniform ferrule (2 mm buccal,
lingual and 0.5 mm proximal) luted with zinc
phosphate cement.
GROUP 3: Uniform ferrule (2 mm buccal,
lingual & 2 mm proximal) luted with resin cement.
GROUP 4: Non uniform ferrule (2 mm buccal,
lingual and 0.5 mm proximal) luted with resin
cement.
GROUP 5: No ferrule luted with zinc
phosphate cement. GROUP 6: No ferrule luted with
resin cement
Ferrule Preparation
Ferrule was prepared using flat end tapered
diamond bur. Length of which was measured using
dial Vernier caliper. Depth of the ferrule was
maintained to 0.6 mm with 3' taper on either side
of the preparation. Teeth in group 1 and 3 were
counterbevelled to receive uniform ferrule of 2 mm
(labial, lingual and proximal). Teeth in group 2 and
4 were counterbevelled to receive non-uniform
ferrule (2 mm labial. 2mm lingual and 0.5 mm
proximal) and teeth in group 5 and 6 received no
ferrule. Post and core pattern were fabricated by
direct method using inlay wax and wooden sprue.
The core was standardized such that the length of
each core pattern was 4 mm. Lingual ledge was
created at the lingual surface of tooth 3 mm below
82
ENDODONTOLOGY MOKSHA NAYAK, KRISHNA PRASADA, DHEERAJ SHETTY

incisal edge to create a standard loading point. The teeth were then stored in saline solution for 3
Casting was done using induction casting machine days prior to fracture testing.
(DEGUSA) with 18 K gold alloy.
Fracture Testing
Cementation of Post Specimens were tested using universal testing
All the 60 specimens had their canal walls machine (INSTRON 4206) set to deliver an
cleaned with 15%EDTA followed by irrigation with increasing load until failure .The crosshead speed
saline which were then dried using absorbent paper of 2.5 mm/min & the load was applied at an angle
points. For teeth in group (1.2& 5) Zinc phosphate of 135 to long axis of tooth. Compressive load was
cement (HARVARD) was mixed to luting applied 3 mm from incisal edge and the force
consistency and then inserted into canal using applied was recorded in kilograms.
lentulo spiral .The posts were then seated into canal
by firm finger pressure. Excess cement was removed
along the peripheries. For teeth in groups (3, 4 &
6) canals were etched with 37% phosphoric acid
for 15 seconds, irrigated with water for a minute &
dried using gentle air blast & absorbent paper
points. Bonding agent (SINGLE BOND 2.3M ESPE)
was then applied to the canal wall using extra fine
brush .After the material had dried for 5 sees, it
was then photo cured for 40 sees using halogen
light curing unit. The resin cement was manipulated
in equal proportions of base & catalyst paste, and
then inserted into the canal using lentulo spiral.
Excess cement was removed followed by photo
curing for 40 seconds using halogen light curing
Figure 1. Specimen mounted in the INSTRON
unit to ensure the cement was cured completely. universal testing machine

Table 2. Comparison of the mean fracture load among the 6 groups using analysis of
variance using ANOVA
N Std. Deviation Minimum Maximum
Uniform Zn phosphate cement { Group 1) 10 45.9000 4.53260 38.00 52.00
Non uniform Zn Phosphate cement ( Group2) 10 27.0000 2.05480 24.00 30.00
Uniform Resin cement { Group 3} 10 51.0000 4.71405 42.00 58.00
Non uniform resin cement ( Group 4) 10 30.3000 3.71334 25.00 36.00
Control Zn phosphate cement ( Group 5) 10 17.8000 2.74064 14.00 22.00
Control Resin cement ( Group 6) 10 22.3000 3.88873 18.00 28.00

a. F=126.163 p< O.001 vhs

83
ENDODONTOLOGY FRACTURE RESISTANCE OF ENDODONTICALLY TREATED TEETH RESTORED WITH CUSTOM CAST POST CORE
USING NON UNIFORM AND UNIFORM FERRULE LENGTH LUTED WITH TWO DIFFERENT CEMENTS: IN-VITRO STUDY.

Table 3 -Multiple comparisons among the six groups using TUKEY USD test
Multiple Comparisons
Dependent Variable: CLOAD TukevHSD

(I) GRP (J) GRP Mean Difference (I-J) P

Uniform Zn Phospate cement (G1) Non uniform Zn Phosphate cement(G2) 18.9000 0.001 vhs
Uniform resin cement ( G3) Non uniform resin cement ( G4) -5.1000 0.038 sig
Control Zn phosphate cement (G5) Control resin cement (G6) 15.6000 0.001 vhs
28.1000 0.001 vhs
23.6000 0.001 vhs
Uniform resin cement { G3} Non uniform resin cement -24.0000 0.001 vhs
( G4) Control Zn phosphate cement ( G5) Control resin cement (G6) -3.3000 0.044 sig
9.2000 0.001 vhs
4.7000 0.042 sig
Non uniform resin cement ( G4) Control Zn phosphate cement 20.7000 0.001 vhs
( G5) Control resin cement(G6) 33.2000 0.001 vhs
28.7000 0.001 vhs
Control Zn phosphate cement ( G5) Control resin cement(G6) 12.5000 0.001 vhs
8.0000 0.001 vhs
Control Zn phosphate cement ( G5) Control resin cement(G6) -4.5000 0.092 ns

Bar graph-showing Comparison of Mean RESULTS

compressive load among the six groups The results were analyzed using analysis of
variance (ANOVA). KRUSKAL WALLIS test and
TUKEY HSD test. The mean fracture load required
to fracture the specimens was maximum for group
3 (51kgs) and minimum for group 5 (17.SO). The
fracture resistance of other groups in descending
order were group 1 (45.9 kgs.), group 4 (30.33 kgs),
group 2 (27 kgs) and group 6 (22.30 kgs). Very high
statistical difference were observed among the
group with uniform ferrule and no ferrule group
and also among the groups luted with resin cement
& zinc phosphate cement .No statistically significant
difference were observed in groups with no ferrule
luted with either of the cements.

DISCUSSION
Endodontic treatment or dehydration causes

84
ENDODONTOLOGY
degradation of physical or mechanical properties
of dentin. Sedgley and Messer support the
interpretation that loss of structural integrity
associated with access preparation rather than
change in dentin lead to higher occurrence of
fracture in endodontically treated teeth compared
to vital teeth. Post is indicated when there is
inadequate coronal tooth structure to retain a core
for an artificial crown and a majority of single rooted
pulpless teeth are restored with post & cores. The
traditional objective for a post was to strengthen
the weakened tooth however, it has been shown
that a post does not strengthen the root (Guzy &
8
Nicholls 1979). The cast gold post & core has
always been regarded as the gold standard in post
& core restorations. It has a history of superior
success rate due to their superior physical
properties. It has been suggested that if a canal
requires a extensive preparation, a well adapted
cast post & core restorations will be more retentive
than a prefabricated post that does not match canal
shape. Morgana & Milot in 1993 questioned the
results of an in vivo study which concludedthat
close adaptation of a post causes more catastrophic
failure. Cast post & core is used when there is
moderate to severe tooth loss.5 The Design of a
dowel is crucial factor affecting the dowel
mechanical behavior in tooth structure in long term
clinical success1. The choice of dowel design
should be in accordance with the biomechanical
requirement of remaining tooth structure. Another
factor that affects the resistance of dowel and core
is the type of cement used.
Goodacre & Spoolnik have recommended 4-
5 mm of gutta-percha remaining apically to
maintain the apical seal. It has been shown that
the forces are concentrated at the crest of the bone
85
MOKSHA NAYAK, KRISHNA PRASADA, DHEERAJ SHETTY
during masticatory function. In the teeth with metal
post, forces also concentrate at the end of the post.
Therefore the post should always extend apically
beyond the crest of the alveolar bone. Preparation
of post space adds a certain degree of risk to a
restorative procedure and also weakens the root
considerably 4. In the present study removal of gutta-
percha was completed using No.3 peeso reamer.
The final post space obtained was parallel with
tapered apical end. In most of studies for fracture
or failure load was done with the continuous force
on testing machine and load values was recorded
and compared. The present study utilized
Houndsfield tensometer to evaluate the fracture
resistance. Loading of tooth at an angle of 135" to
its long axis was chosen in the present study to
simulate a contact angle in class 1 occlusion
between maxillary and mandibular anterior teeth.
In vitro experiments with extracted teeth
hardly replicate with reliability the behavior of the
teeth in the mouth when a vital periodontal
ligament is present.13 Studies have simulated the
periodontal ligament by adding a fine layer of
elastomer to cover the root surface. Since the
purpose of this study was to compare in vitro
experimental group, such procedure was not
relevant. The experimental conditions for all groups
were identical. Two factors were analyzed in the
present the study the effect of varying ferrule lengths
and the luting cement. In the experimental design,
tooth preparation extended around the external
periphery providing a gold collar bracing the
cervical part of tooth(core ferrule). Majority of the
studies investigate the effect of crown ferrule (2 mm
parallel of parallel walls of dentin surrounding
cervical portion of crown ) on fracture resistance
of tooth, however, very few studies investigated
ENDODONTOLOGY
USING NON UNIFORM AND UNIFORM FERRULE LENGTH LUTED WITH TWO DIFFERENT CEMENTS: IN-VITRO STUDY.
the effect of core ferrule on fracture resistance on
endodontically treated tooth.
Resistance refers to ability of the post and the
tooth to withstand lateral and rotational forces.
Ferrule effect adds to some retention but primarily
provides resistance form and enhance longevity. 5
The result of the current study showed a higher
fracture resistance in group with ferrule (group
1,2,3,4) than in no ferrule group (group 5.6). As in
the present study most other studies (4,5,25) have
demonstrated the positive effect of ferrule design
incorporated in the preparation of teeth with post
and core. Ferrule maintains the structural integrity
of root under functional loading, homogenous
transmission of functional forces along the
dowel2".Core ferrule encircles the sound tooth
structure at 360° serves as a reinforcing ring to
protect tooth structure from vertical fracture. A
contra bevel (core ferrule) also acts as a secondary
ferrule independent of the ferrule provided by cast
crown (crown ferrule).6
The present study regarded 2 mm uniform
ferrule (group 1.3) as a key to restoration longevity
and had the maximum fracture resistance (51 &
45.9 kgs) compared to non uniform (group 2.4) and
no ferrule (group 5.6) (I7.S & 22.3 kgs). Roots resist
better multiple stresses to which they arc subjected
to when tooth is in use and even to loads from
parafunctional habit. These results are also in
9
accordance with the other studies which states with
the use of cyclic loading, a ferrule length of 2 mm
decrease the risk of loosening of either post or
crown. The present study showed a maximum
fracture resistance in group 3 (51 kg) and a
minimum fracture resistance in group 5(17.8 kg),
the groups with uniform ferrule (group 1, 3) were
FRACTURE RESISTANCE OF ENDODONTICALLY TREATED TEETH RESTORED WITH CUSTOM CAST POST CORE
in permissible limits of maximum loading force in
extreme bruxism. The results also indicate that the
tooth with uniform, non uniform & no ferrule luted
with zinc phosphate or resin cement could survive
the normal occluding forces1 . Strankicwez and
Wilson reviewed that a ferrule with 1 mm vertical
height has been shown to double the fracture
resistance of teeth in groups of teeth with ferrule
compared to no ferrule group. Similar results were
obtained in the present study with the 2 mm
uniform ferruled groups showing double fracture
resistance compared to no ferrule groups. Post
retention refers to ability of post to resist vertical
dislodging forces. Luting cement is one of the
important factors for retention.15 In the present
invitro study 2 mm uniform ferrule luted with resin
cement showed statistically higher fracture
resistance among all ferruled groups.. This result
can be analyzed in the light of physical and
chemical properties of resin cement which presents
micromechanical and chemical bond to dentin that
is not observed in zinc phosphate cement.
Moreover the modulus of elasticity of resin cement
(1/4 - 1/6 of dentin) is much lower than zinc
phosphate cement (22.4 Gpa) and dentin (18.6
Gpa). However modulus of elasticity allows stresses
to dissipitate rather than concentrate in the residual
root. Added advantage of resin cement is that it
allows the post to bond to dentin, increase
retention, lends to leak less than other cement and
provide short term strengthening of the roots. Reid
et al and junge et al reported that post cemented
with resin cement were more resistant to cyclic
loading than those cemented with zinc phosphate
cement. It is generally believed that eugenol
containing root canal sealers inhibit the
polymerization of resin cement, all though zinc
86
ENDODONTOLOGY
oxide eugenol sealer was used in the study it is
reported that problem can be avoided by thorough
cleaning and etching of canal walls.According to
study by Varela et al, concerns about the negative
effective of sodium hypochlorite irrigation on resin
adhesion to dentin also are unfounded.26 However
the resin cement have the disadvantage of being
technique sensitive than other luting cements.
Contradiction to our results, AL Hazamimeh &
Gutteridge found that preparation designs that
incorporated a ferule & those that did not showed
no difference in fracture resistance s. The authors
suggested the similarity between the groups may
have resulted from the resin cement strength
masking the effect of the ferrule; however these
studies utilized prefabricated post and core. It is
interestingly noted in the present study that there
was no statistical difference between the two
cements in control group (group 5, 6), where no
ferrule was utilized. The reason attributed to this
relates to the resin cement bonding to dentin is
decreased, reduced surface area for etching &
bonding of metal to tooth structure, absence of
encircling band of metal collar bracing the tooth.
As with all in vitro research, this study application
may be limited in clinical situation. The elasticity
of periodontal ligament, bone & tooth including
the differences in functional forces in
stomatognathic system were not simulated in the
study. It can be postulated that occlusal forces must
be resisted exclusively by the post that may
eventually fracture otherwise vertical root fracture
may occur. Resin adhesion to dentin has been
shown to decrease with time in vitro and in vivo.
Initial benefits are lost because of repeated thermal,
chemical and mechanical stresses of oral cavity.
Furthermore laboratory researches coupled with
87
MOKSHA NAYAK, KRISHNA PRASADA, DHEERAJ SHETTY
randomized controlled clinical trials are indicated
to confirm the results.
CONCLUSION
Within the limitations of the study the
following conclusions were drawn:
1. When tested with a single angle
compressive load the custom cast gold post core
with ferrule had higher fracture resistance than non
ferruled groups.
2. Group with 2 mm uniform ferrule luted
with resin cement showed the highest fracture
resistance ( 51.00 kgs) & group with no ferrule luted
with zinc phosphate cement showed the least
resistance (17.8O kgs).
3. 2 mm uniform ferruled specimens had
higher compressive load at failure compared to lion
ferruled specimens.
4. Adhesive resin cement tested appeared to
have significantly higher fracture resistance in
uniform and non uniform ferruled groups compared
to groups luted with zinc phosphate cement.
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