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ORIGINAL RESEARCH Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 1  |  Page : 17-21
The effect of post-core and ferrule on the fracture resistance of endodontically treated maxillary central incisors


Department of Prosthodontics, Meenakshi Ammal Dental College, Maduravoyal, Chennai - 600 095, Tamil Nadu, India

Click here for correspondence address and email

Date of Submission26-Dec-2006
Date of Decision18-Jul-2007
Date of Acceptance20-Jul-2007
 

   Abstract 

Aim: To evaluate the effect of post reinforcement, post type and ferrule on the fracture resistance of endodontically treated maxillary central incisors.
Materials and Methods: Sixty central incisor teeth were selected and grouped into six groups, viz. A, B, C, D, E, and F, each consisting of 10 specimens. Group A specimens were not subjected to any restorative treatment. Group B specimens were endodontically treated and crowned. Specimens of groups C and D were restored with custom cast post and core. Specimens of groups E and F were treated with prefabricated titanium post and composite core. Specimens of groups C and E were restored with porcelain-fused metal (PFM) crown having 2 mm ferrule. Specimens of groups D and F were restored with PFM crown having no ferrule. All the specimens were subjected to load (newton, N) on the lingual surface at a 135° angle to the long axis with a universal testing machine until it fractured. The fracture load and mode of fracture of each specimen were noted. One-way analysis of variance with Tukey honestly significant difference procedure was employed to identify the significant difference among the groups at 5% level (P < 0.05).
Results: There were significant differences among the six groups studied (P < 0.0001). The highest fracture strength was recorded with specimen of group C (1376.7 N). There were significant differences between groups A and D versus groups B, E, and F. There were no significant differences between groups B, E, and F. Cervical root fracture was the predominant mode of failure in all the groups except group A.
Conclusion: The results showed that endodontically treated teeth restored with custom cast post core were as strong as the untreated group. Teeth restored with custom cast post core were better resistant to fracture than teeth restored with prefabricated titanium post and composite core. Ferrule is more important in custom cast post core than in prefabricated post and composite core.

Keywords: Endodontically treated teeth, fracture resistance, post and core

How to cite this article:
Sendhilnathan D, Nayar S. The effect of post-core and ferrule on the fracture resistance of endodontically treated maxillary central incisors. Indian J Dent Res 2008;19:17-21

How to cite this URL:
Sendhilnathan D, Nayar S. The effect of post-core and ferrule on the fracture resistance of endodontically treated maxillary central incisors. Indian J Dent Res [serial online] 2008 [cited 2020 Oct 27];19:17-21. Available from: https://www.ijdr.in/text.asp?2008/19/1/17/38926
Restoration of endodontically treated teeth is a challenging endeavor. They are more prone to fracture due to loss of moisture supplied by the vital pulp. Extensive structural defects due to decay, trauma, and prior restoration call for post and core restoration. Many techniques have been advocated for post and core fabrication. Custom cast post core has been regarded a "gold standard" in post and core restoration. Bregman [1] reported 90.6% success rate after 6 years of service for custom cast post core. Fabrication of custom cast post core is a two-stage procedure. Prefabricated post and composite resin core build-up simplifies the procedure into single stage. Scientific literature reveals many controversies regarding the use of different post core systems in the management of endodontically treated teeth. Lovdahl and Nicholls [2] found that endodontically treated unrestored teeth were twice as resistant to fracture than the post-reinforced teeth. Zhi-yue and Yu-Xing [3] reported that teeth with custom cast post core were more resistant to fracture than endodontically treated teeth. Isidor et al . [4] observed that prefabricated post and composite core are more resistant to cyclic loading than custom cast post and core. Heydecke et al . [5] found no difference in fracture resistance between prefabricated post core and custom cast post core. Dental ferrule is an encircling band of cast metal around the coronal surface of the teeth. The use of ferrule as a part of the artificial crown was proposed in reinforcing the root-filled teeth. [6] However, the need of ferrule in prefabricated post and core is questioned by Al-Hazaimeh and Gutteridge. [7]

Therefore, the present study was aimed to evaluate fracture resistance of endodontically treated teeth restored using custom cast post and core or prefabricated post and composite core with or without ferrule in the artificial crown. The objectives were:

  1. To compare the fracture resistance of untreated teeth with endodontically treated teeth.
  2. To compare the fracture resistance of endodontically treated teeth with and without post-reinforcement.
  3. To compare the fracture resistance of custom cast post core and prefabricated post and composite core.
  4. To evaluate the effect of ferrule on the custom cast post core and prefabricated post and composite core.



   Materials and Methods Top


A total of 60 human maxillary central incisors were selected from a collection of extracted teeth stored in a solution of neutral buffered formalin for less than 3 months at room temperature. Teeth with root caries, restorations, previous endodontic treatment, and cracks observable at a magnification of 2× were not included.

Sixty teeth were divided into six groups, each containing 10 specimens, namely A, B, C, D, E, and F [Table - 1]. No restorative treatment was performed on the teeth of group A. Group B specimens were endodontically treated and crowned. The specimens of groups C and D were restored with custom cast post and core. The specimens of groups E and F were treated with prefabricated titanium post and composite core. The length of each tooth was measured from apex to incisal edge. The labiolingual and mesiodistal dimensions of each tooth were recorded at the level of cervical margin. All the dimensions were measured using a digital caliper (Denta Gauge, Eriskine Dental, USA). Analysis of variance (anova) with Tukey honestly significant difference (HSD) was employed to identify the difference between the groups at 5% ( P < 0.05) [Table - 2]. Initial silicone index for each tooth was made with putty polyvinyl siloxane impression material (Provil, Heraeus Kulzer, USA) to aid in the fabrication of final restoration.

The teeth in groups C, D, E, and F were decoronated with a diamond bur (Mani Inc., Japan) using a high-speed handpiece (NSK, Japan) under air-water spray. Teeth in groups C and E were cut 3 mm above the cementoenamel junction to provide 2 mm of remaining coronal dentin. Teeth in groups D and F were cut 1 mm above the cementoenamel junction at a level corresponding to 1 mm below the clinical gingival margin. All the teeth were then stored in 0.9% sodium chloride solution at room temperature.

In samples of group B, access openings were made. In the specimens of groups B to F, root canals were prepared using K-files (Mani Inc., Japan) and were finished to no. 50 files. The prepared canals were coated with zinc oxide-eugenol cement (Deepti Dental Products, India) and filled with laterally condensed gutta-percha points (Densply, India).

Each tooth in groups B to F was prepared using the high-speed handpiece under air-water spray to receive a porcelain-fused metal crown. All the teeth were prepared by the same operator. A flat-end tapered diamond was used to achieve a uniform reduction of 1 mm with 8-10° taper. No attempts were made to standardize the preparation taper. A shoulder finish line of 1 mm width was prepared 1 mm above the cementoenamel junction. Overall reduction was confirmed by the use of the initial silicone index. After preparation, all the teeth were stored in 0.9% NaCl at room temperature.

Post and core fabrication

Two weeks after root canal treatment, post channels were prepared. Specimens of groups C and D were prepared using Peeso Reamer (Mani Inc) starting from no.1 to no. 5 in a slow-speed handpiece (NSK), leaving a 4-mm apical seal. Root canals were coated with a thin layer of petrolatum using paper points. Direct resin post and core patterns were made using auto-polymerizing acrylic resin (DPI, India). The patterns were invested and cast in Ni-Cr alloy (Wiralloy, Bego, Germany). After casting, minor imperfections were removed, if present. The post and core were tried with the corresponding teeth. Zinc phosphate cement (Harvard Cement, Germany) was used to cement groups C and D post cores. The cement was mixed according to the manufacturer's direction using glass slab and cement spatula and spun into the channels with a lentulo spiral (Brassler, USA) before seating the castings firmly with finger pressure for 5 min.

Specimens of groups E and F were prepared initially using Peeso Reamer starting from no. 1 to no. 4 and finished using no. 4 Dentatus Post Reamer (Dentatus, Sweden) of 1.5 mm diameter in a slow-speed handpiece to accommodate Dentatus L Prefabricated Post (Dentatus) of 11.5 mm length leaving a minimum of 4 mm apical seal. Post head of 1.5 mm was extending over the post space. The posts were cemented with zinc phosphate cement. The cement was mixed according to the manufacturer's direction using a glass slab and cement spatula and spun into the channels with a lentulo spiral before seating the posts firmly with finger pressure for 5 min. The coronal core portion was made with light polymerized core build-up composite resin (Heraeus Kulzer, USA). The remaining coronal tooth portion and post head were etched (Gluma Etch; Heraeus Kulzer, USA) for 15 s, rinsed, and air-dried. Two layers of a dentin bonding agent (Gluma-comfort Bond; Heraeus Kulzer) were applied to the cervical dentin and coronal portion of the post and were light polymerized for 20 s. Three increments of the composite were applied to complete the coronal core, each requiring 40 s of photo-polymerization to complete the coronal core. Radiographs were made in labiolingual and mesiodistal direction for each specimen to determine whether there was more than 1 mm remaining root dentin around the post.

Preparation for porcelain-fused metal (PFM) crowns

Impressions of prepared specimens were made with polyvinyl siloxane impression material using plastic trays and were poured using die stone. PFM crowns were fabricated using Ni-Cr alloy and vita VMK95 porcelain by a skilled technician, who was uninformed of the group design. The form of the final PFM crown was confirmed with the initial silicone index. Zinc phosphate cement was used to cement the crowns. The prepared specimens were then stored in 100% humidity for 30 days at room temperature to simulate the humidity in vivo until they were returned for testing.

Fracture strength testing

A custom-made jig, which would fit exactly in the retaining arm of the universal testing machine, was made [Figure - 1]. It had a rectangular block of metal placed 6 mm from the center of the proposed loading axis. The rectangular block had a hole of 12 mm diameter, which was designed to be at 135° to the proposed path of loading. Die stone analog of the hole was obtained from the putty polyvinyl siloxane impression material. Central line was marked using a protractor in the die stone analog. Teeth were mounted parallel to the central line using an auto-polymerizing acrylic resin, which was positioned 2 mm below the cementoenamel junction. The custom-made jig was positioned in the universal testing machine. The mounted teeth were placed in the custom-made jig. A steel rod with a rounded end in the universal testing machine was used to load the teeth at the angle of 135° to the long axis of the teeth with a cross-head speed of 5 mm min -1 . All the teeth were loaded 3 mm below the incisal edge at the middle of the lingual surface [Figure - 2]. The specimens were loaded until fracture occurred. The load values were measured in newtons (N). The mode of fracture of each specimen was recorded.

Statistical analysis

One-way anova was used to compare the mean loads for each group. The dependent variable was the load required to fracture the specimens. Tukey HSD procedure was employed to identify the significant groups at 5% level. All the results were considered statistically significant if P < 0.05.


   Results Top


Mean failure loads were calculated for all groups [Table - 3]. The highest mean fracture resistance recorded for group C teeth (custom cast post core with 2 mm ferrule) was 1376.7 N followed by group A (natural tooth - 1087.9 N) and group D (cast post core without ferrule - 1079.9 N). The mean fracture resistance of group C was significantly higher than all other groups ( P < 0.0001). The mean fracture resistance of groups A and D was statistically significant than that of groups B (crowned, endodontically filled teeth), E (prefabricated post and composite core with 2 mm ferrule), and F (prefabricated post and composite core without ferrule). There was no statistical difference between groups B, E, and F specimens. [Table - 4] shows the mode of failure of each group after loading. There were four typical fracture modes, namely crown fracture, cervical root fracture, mid root fracture, and apical root fracture. Vertical root fractures were not observed in this study. Cervical root fracture is the predominant mode of fracture in all the groups except group A, where crown (tooth) fracture was the major mode of fracture. In two of the group B specimens, porcelain fracture of the PFM crown was observed.


   Discussion Top


The results of the present study indicate that custom cast post core systems improve the fracture resistance of endodontically treated teeth. Strengthening of the endodontically treated tooth by post core restoration depends on the post core system used and the ferrule length. The fracture resistance of custom cast post core (groups C and D) was significantly higher than prefabricated post and composite core (groups E and F). This is in agreement with results of the studies conducted by Martinez-Insua et al. [8] and Zhi-Yue and Yu-Xing. [3] The reasons for increased fracture resistance are:

  1. The custom cast post core was made to fit the shape of the post space, which helps in better transmission of the stress.
  2. It was more rigid than the titanium prefabricated post tested. [9]


In this study, it was observed that the fracture resistance of endodontically treated maxillary central incisors restored without any post (group B) performed similar to prefabricated post-reinforced teeth (groups E and F). Thus, by reinforcing the endodontically treated teeth with minimum tooth structure with post and core, its fracture resistance can be made at par with that of a crowned endodontically treated tooth. It was demonstrated that there is a decrease in fracture resistance from natural tooth (group A) to crowned endodontically treated tooth (group B). It is due to the fact that crowned endodontically treated teeth was weakened centrally by the access cavity preparation and peripherally by the preparation needed to accommodate both ceramic and metal. Thus, the recommendation of Schillingburg et al. [10] that endodontically treated teeth that require metal ceramic crowns need a post core restoration seems to be logical.

Many studies have been carried out to investigate the ferrule effect in root-filled teeth, and many suggest that ferrule should increase resistance to fracture. [11],[12] To achieve the full benefit of ferrule effect, it should be a minimum of 1-2 mm in height, have parallel dentine walls totally encircling the tooth, and ending on sound tooth structure. The consensus is that:

  1. A properly constructed ferrule significantly reduces the incidence of fracture in nonvital teeth by reinforcing the teeth at its external surface and redistributing the applied forces, which concentrate at the narrowest point around the circumference of the tooth. [7]
  2. It helps to maintain the integrity of the cement seal of the crown. [12]


It has been suggested by Eissmann and Radke [13] that maintaining 2 mm of tooth structure above the gingival margin is beneficial. In contrast, others found no benefit of adding a ferrule to the preparation of endodontically treated tooth. [6],[14] Only a few authors have considered prefabricated post and cores. Al-Hazaimeh and Gutteridge [7] questioned the additional need of ferrule on a crowned tooth incorporating a prefabricated post and composite core. The present study was aimed at comparing the effect of ferrule on the custom cast post core and prefabricated post core. The ferruled specimens (groups C and E) when compared to their corresponding unferruled specimens (groups D and F) showed higher mean fracture load. However, statistically significant result was noted only in custom cast post core. No such difference was observed in prefabricated post and composite cores.

Pierrisnard et al. [9] in their finite element analysis noted that the cervical region of post-restored teeth was subjected to maximum tensile stress, which increases the risk of fracture. Many studies have been reported stating cervical third root fracture as the major mode of fracture. [5],[8] Zhi-Yue and Yu-Xing [3] reported apical third root fracture as the common mode of fracture. In the present study, cervical third root fracture was the predominant fracture pattern. Such mode of fractures can be restored in clinical situation. The tapering end post design used in the study resulted in less number of apical root fracture, which, in a clinical situation, would demand extraction of the tooth itself.


   Conclusion Top


The following conclusions were drawn from the study:

  1. The results showed that endodontically treated teeth restored with custom cast post core were as strong as the untreated group.
  2. Teeth restored with custom cast post core with 2 mm ferrule showed highest resistance to fracture.
  3. Teeth restored with custom cast post core showed better resistance to fracture than teeth restored with prefabricated titanium post and composite core. Hence, in incisors, cast post cores are preferred to other systems.
  4. Ferrule had a significant role in the fracture resistance of custom cast post core restored teeth.
  5. Additional use of ferrule preparation on a crowned tooth incorporating a prefabricated post and composite resin core restoration provided no improvement in fracture resistance.



   Acknowledgement Top


We would like to acknowledge Dr. K. Chandrasekaran Nair, MDS, Professor and Head, Department of Prosthodontics, Maruti Dental College, Bangalore, for his timely suggestions.

 
   References Top

1.Bregman B, Lundquist P, Sjogren U, Sundquist G. Restorative and endodontic results after treatment with cast posts and cores. J Prosthet Dent 1989;61:10-5.  Back to cited text no. 1    
2.Lovdahl PE, Nicholls JI. Pin retained amalgam cores Vs cast - gold dowel cores. J Prosthet Dent 1977;38:507-14.  Back to cited text no. 2  [PUBMED]  
3.Zhi-Yue L, Yu-Xing Z. Effects of post-core design and ferrule on fracture resistance of endodontically treated maxillary central incisors. J Prosthet Dent 2003;89:368-73.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Isidor F, Brondum K, Ravnholt G. The influence of post length and crown ferrule length on the resistance to cyclic loading of bovine teeth with prefabricated titanium posts. Int J Prosthodont 1999;12:78-82.  Back to cited text no. 4    
5.Heydecke G, Butz F, Hussein A, Strub JR. Fracture strength after dynamic loading of endodontically treated teeth restored with different post and core systems. J Prosthet Dent 2002;87:438-45.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63:529-36.  Back to cited text no. 6  [PUBMED]  
7.Al-Hazaimeh N, Gutteridge DL. An in-vitro study into the effect of the ferrule preparation on the fracture resistance of crowned teeth incorporating prefabricated post and composite core restoration. Int Endod J 2001;34:40-6.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Martinez-Insua A, Silva LD, Rilo B, Santana U. Comparison of the fracture resistance of pulpless teeth restored with a cast post and core or carbon-fiber post with a composite core. J Prosthet Dent 1998;80:527-32.  Back to cited text no. 8    
9.Pierrisnard L, Bohin F, Renault P, Barquins M. Corono-radicular reconstruction of pulpless teeth: A mechanical study using finite element analysis. J Prosthet Dent 2002;88:442-8.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Schillingburg HT, Hobo S, Whisett CD, Jacobi R, Brackett SE, editors. Fundamentals of fixed prosthodontics. Quintessence; Chicago: 1997. p. 181-209.  Back to cited text no. 10    
11.Milot P, Stein SR. Root fracture in endodontically treated teeth related to post selection and crown design. J Prosthet Dent 1992;68:428-35.  Back to cited text no. 11    
12.Libman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodont 1995;8:155-61.  Back to cited text no. 12  [PUBMED]  
13.Eissmann HF, Radke RA. Post endodontic restoration. In: Cohen S, Burns RC, editors. Pathways of the pulp. Mosby: St. Louis, Mo, USA; p. 640-83.  Back to cited text no. 13    
14.Tjan AH, Whang SB. Resistance to root fracture of dowel channels with various thicknesses of buccal dentin walls. J Prosthet Dent 1985;53:496-500.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Dakshinamurthy Sendhilnathan
Department of Prosthodontics, Meenakshi Ammal Dental College, Maduravoyal, Chennai - 600 095, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.38926

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    Figures

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    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]

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