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Effect of a crown ferrule on the fracture resistance of endodontically treated

teeth restored with prefabricated posts


Jefferson Ricardo Pereira, DDS, MSc,a Fabio de Ornelas, DDS,b Paulo Cesar Rodrigues Conti,
DDS, MSc, PhD,c and Accacio Lins do Valle, DDS, MSc, PhDc
Department of Prosthodontics, Bauru Dental School, University of Sao Paulo, Sao Paulo, Brazil
Statement of problem. Root fracture is one of the most serious complications following restoration of
endodontically treated teeth.

Purpose. The purpose of this study was to compare the fracture strengths of endodontically treated teeth using
posts and cores and variable quantities of coronal dentin located apical to core foundations with corresponding
ferrule designs incorporated into cast restorations.
Material and methods. Fifty freshly extracted canines were endodontically treated. The teeth were randomly
divided into groups of 10 and prepared according to 5 experimental protocols. Control group: teeth with custom cast post and core; 0-mm group: teeth without coronal structure (no ferrule); 1-mm, 2-mm, and 3-mm
groups: teeth with 1 mm, 2 mm, and 3 mm of remaining coronal tooth structure (1-, 2-, and 3-mm ferrule),
respectively. All specimens in 0-mm through 3-mm (noncontrol) groups were restored with a prefabricated post
(Screw-Post) and composite resin (Z100) core located superior to the different tooth structure heights. All teeth
were restored with complete metal crowns. The fracture resistance (N) was measured in a universal testing
machine at 45 degrees to the long axis of the tooth until failure. Data were analyzed by 1-way analysis of variance
and Tukey test (a=.05).
Results. Significant differences (P,.001) were found among the mean fracture forces of the test groups (control group: 818.2 N; 0-mm, 1-mm, 2-mm, and 3-mm groups: 561.0 N, 627.6 N, 745.3 N, and 907.1 N,
respectively). When the mode of failure was evaluated, all failures in the control group occurred due to root fracture, and all failures in the 0-mm group occurred due to core fracture. The majority of failures in the other
groups occurred due to crown cementation failure.
Conclusion. The results of this study showed that an increased amount of coronal dentin significantly increases
the fracture resistance of endodontically treated teeth. (J Prosthet Dent 2006;95:50-4.)

CLINICAL IMPLICATIONS
This in vitro study demonstrated that increasing the size of ferrule designs in crowns had a significant effect on the fracture resistance of endodontically treated teeth restored with prefabricated posts and composite resin cores.

he restoration of endodontically treated teeth is an


important aspect of dental practice that involves a range
of treatment options of varying complexity. The challenge may be complicated by substantial loss of coronal
tooth structure and the ability to predict restorative success. The likelihood of survival of a pulpless tooth is
directly related to the quantity and quality of the
remaining dental tissue.1 A post is usually placed in an
attempt to strengthen the tooth.2-4 However, in vitro
and in vivo studies have demonstrated that a post does

Supported by CAPES (Coordenacao de Aperfeicoamento de Pessoal


de Nivel Superior) Coordination of the Improvement of People
of Superior Level.
a
Postgraduate student, Doctorate program, Oral Rehabilitation.
b
Postgraduate student.
c
Professor, Department of Prosthodontics.

50 THE JOURNAL OF PROSTHETIC DENTISTRY

not reinforce endodontically treated teeth.5-9 Posts are


required for supporting a core foundation when there
is insufficient clinical crown remaining.5-9
Although cast post-and-core restorations are the gold
standard for endodontically treated teeth, prefabricated
post systems are popular when coronal tooth structure is
missing because they save time and can provide satisfactory results.10-12 Despite efforts to reinforce endodontically treated teeth with internal posts and cores, tooth
fracture continues to occur.4 Some authors13,14 demonstrated that roots restored with cast posts exhibited significantly higher internal stresses than prefabricated
posts. With recent improvements in the bonding of
composite resin to dentin, true internal retention may
assist with treatment success.5,15-17
The availability of 2.0 mm of coronal tooth structure
between the crown preparation shoulder and the
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PEREIRA ET AL

tooth/core junction was found to enhance fracture resistance.18 It appears that this extension of coronal tooth
structure provides the greatest influence in terms of resistance and retention form for a crown.19,20 Several authors8,21,22 have suggested that a tooth should have a
minimum of 2 mm of coronal structure above the cementoenamel junction (CEJ) to ensure proper resistance form for a tooth. This 2 mm of tooth structure
will provide a ferrule effect with the artificial crown
that should prevent fracture of the root, fracture of the
post, and dislodgement of the post.23-26 Gegauff 25 evaluated the effect in vitro of simulated surgical crown
lengthening and found that there was no significant difference between the amount of remaining coronal structure and fracture resistance. Thus, authors have different
opinions about the ideal amount of remaining coronal
tooth structure. The fracture resistance of endodontically treated teeth restored using cast posts or prefabricated posts as described in the literature may be
acceptable, clinically, because the reported fracture resistance is considerably higher than the maximal physiologic forces acting on the teeth in the oral cavity.27
The purpose of this study was to compare the fracture
resistance of endodontically treated teeth with varying
amounts of coronal tooth structure available for crown
preparation with the remaining tooth structure restored
with prefabricated posts and complete metal crowns.
The research hypothesis was that the amount of coronal
structure would have a significant effect on fracture
resistance and type of fracture.

MATERIAL AND METHODS


Fifty recently extracted maxillary canines with similar
root lengths (between 15 mm and 16 mm measured
with a millimeter ruler from the apex to the CEJ) were
selected from 93 maxillary canines extracted for periodontal reasons. The teeth were stored in distilled water
at a temperature of 37C. Teeth were selected for inclusion if they were without root-surface carious lesions or
fissures and had not previously been subjected to endodontic therapy. Each canal was prepared to within
1 mm of the radiographic apex with a standard master
apical file #20 (Dentsply-Maillefer, Ballaiguess,
Switzerland). Master apical files (Dentsply-Maillefer)
3 sizes larger (#25, #30, and #35) than the initial instrument were used to further prepare the canal. The
root canal for each tooth was instrumented with a
conventional step-back technique to an International
Standardization Organization (ISO) file #35 (Dentsply
Maillefer) at the apex. The canals were irrigated with
2.5% sodium hypochlorite solution (Asfer Industrial
Qumica, Sao Paulo, Brazil) throughout the preparation
and dried with paper points (Tamari; Tamariman
Industrial Ltd, Macacaruru, Brazil). Each canal was obturated by lateral condensation using gutta-percha
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THE JOURNAL OF PROSTHETIC DENTISTRY

points (Tamari; Tamariman Industrial Ltd) and an


ISO 35 primary gutta-percha master cone (Tamari;
Tamariman Industrial Ltd). Root canal cement (Endometazone Ivory; Septodont Brasil, Barueri, Sao Paulo,
Brazil) was used as the sealer. Post preparations were
made with a #5 reamer (Largo; Dentsply-Maillefer)
to remove 9 mm of gutta-percha apical to the CEJ
from each filled canal. After post-space preparation,
the teeth were randomly divided into 5 groups of 10
teeth each by drawing lots.
For the control group, the coronal aspects of the
teeth were removed at the CEJ perpendicular to the
long axes of the teeth. The canal of each tooth was restored with a custom cast post and core with the same
size and shape as the prefabricated posts. A direct technique was used to fabricate the post-and-core patterns
in acrylic resin (Duralay; Reliance Dental Mfg Co,
Chicago, Ill). A Cu-Al alloy (NPG; AalbaDent, Cordelia, Calif) was used to cast the post-and-core patterns.
The patterns were invested (Cristobalite; Whip Mix
Corp, Louisville, Ky) and cast.
The teeth in the 0-mm group were prepared similarly
to those in the control group, except that the canals were
restored with prefabricated stainless steel, parallel-sided,
serrated posts with a tapered end (Screw-Post; EuroPost Anthogyr S.A., Sallanches, France). All posts were
cemented with glass-ionomer cement (Rely X; 3M
ESPE, St. Paul, Minn). The cement mix was prepared
according to the manufacturers instructions and
introduced into each root canal with a lentulo spiral
drill (Dentsply-Maillefer) on a low-speed handpiece.
Cement was placed on the post and seated under finger
pressure. During cementation, the loading pressure was
released and the post was gently reseated and held in
place until final setting of the cement. Excess cement
was removed and each specimen was returned to storage
in distilled water.
The dentin was etched with 37% phosphoric acid, and
a bonding agent (Primer-Bond 2.1; Dentsply Ind, Com,
Ltd, Petropolis, Rio de Janeiro, Brazil) was placed on
the dentin as recommended by the manufacturer. The
composite resin cores were standardized using a coreforming matrix (TDV Dental, Ltd, Pomerode SC,
Brazil) and a composite resin (Z100; 3M ESPE). The
composite resin was placed using an incremental technique. Five increments of the composite resin were
applied, each requiring 40 seconds of polymerization
to complete the coronal core. A polymerization unit
(Ultraled; Dabi Atlante, Ribeirao Preto, Sao Paulo,
Brazil) (110 W) was used to light polymerize the composite resin specimens. The tip of the light was positioned 2 cm from the specimens at the top of the core.
For the 1-mm group, the coronal tooth structure was
reduced to a flat plane at a height of 1.0 mm incisal to the
CEJ, circumferentially, and restored similar to the 0-mm
group, except with the core material beginning 1 mm
51

THE JOURNAL OF PROSTHETIC DENTISTRY

PEREIRA ET AL

Fig. 1. Coronal tooth structure was reduced to flat plane at


height of 0 mm, 1 mm, 2 mm, and 3 mm (left to right).

above the CEJ (Fig. 1). For the 2-mm and 3-mm
groups, the coronal tooth structures were reduced to a
flat plane at heights of 2.0 mm and 3.0 mm incisal to
the CEJ, respectively, and restored in the same manner
as the 1-mm group.
All specimens were prepared with a diamond rotary
cutting instrument (#3216; KG Sorensen, Barueri, Sao
Paulo, Brazil) in a high-speed handpiece with water
spray (Super Torque 625 Autofix; KaVo do Brazil Ind,
Com, Ltd, Joinville, SC, Brazil). Specimens were prepared to receive complete crowns (1.5-mm facial reduction with a chamfer finish line and 0.5-mm chamfered
lingual reduction). The finish lines for all specimens
were placed at the level of the CEJ. An impression
was made using a vinyl polysiloxane impression material (Aquasil; Dentsply DeTrey GmbH, Konstanz,
Germany) of the tooth prior to preparation and used
to fabricate the wax pattern. Wax (Kerr Corp, Orange,
Calif) was then poured into the impression; the tooth
was inserted into it. After the wax cooled, the impression
was removed and the margins were perfected. The wax
patterns were sprued, invested (Cristobalite; Whip Mix
Corp), and cast in a Ni-Cr alloy (Durabond, Sao Paulo,
Brazil). Crowns were luted to the teeth with glass-ionomer cement (Rely X; 3M ESPE).
The root surface of each tooth was coated with a layer
(approximately 60 mm) of silicone impression material
(Aquasil; Dentsply DeTrey) to simulate a periodontal
ligament.28 Root surfaces were marked 2 mm below
the CEJ and covered with a 0.6-mm-thick foil (Adapta
foil; BEGO, Bremen, Germany). All specimens were
embedded in acrylic resin (Artigos Odontologicos
Classico S/A, Sao Paulo, Brazil) poured into molds
made of the same material (30 mm high and 22 mm
in diameter, with an internal opening in the center of
the mold 20 mm high and 10 mm in diameter). The
teeth were embedded along their long axes using a surveyor (Bio-Art Equipamentos Odontologicos Ltd, Sao
Carlos, SP, Brazil) and placed in a cool water bath during the polymerization of the resin. After the first signs
of polymerization, teeth were removed from the resin
blocks along their long axes using the surveyor, and
52

Fig. 2. Specimens were subjected to load at 45 degrees on a


universal testing machine.

spacers (Adapta) were removed from the root surfaces.


Silicone-base impression material (Aquasil; Dentsply
DeTrey) was injected into the acrylic resin blocks, and
the teeth were reinserted into the resin cylinders. A standardized silicone layer that simulated periodontal ligament was thus created.
Each specimen was placed in a custom apparatus that
allowed the specimen to be positioned at 45 degrees to
the buccal/lingual long axis. The specimens were subjected to loading at this orientation in a universal testing
machine (Kratus K2000 MP; Dinamometros KRATOS
Ltd, Sao Paulo, Brazil) (Fig. 2). A crosshead speed of
0.5 mm/min was applied until failure. The load was
measured in newtons (N). Failure was defined as fracture
of the core material with displacement from the post
head, or when fracture affected the core or the tooth.
The mode of failure was recorded after the test using a
34 binocular loupe (Bio-Art Equipamentos Odontologicos Ltd).
The data were analyzed with a 1-way analysis of variance (ANOVA) to determine the overall differences
among the mean values of the test groups and the overall
variability within the test groups. The Tukey multiple
comparison test was used to determine which test
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Table I. Resistance to failure of test specimens: mean values


and SDs of test groups and Tukey comparisons

Table II. One-way ANOVA

Groups

Effect

0 mm
1 mm
2 mm
Control
3 mm

Mean (N)

561.0a
627.6ab
745.3abc
818.2bc
907.1c

SD

136.8
122.6
144.8
147.9
269.9

df
effect

MS
effect

df
error

2040.936

45

Type of
restoration

RESULTS
Table I summarizes the mean fracture resistance for
the 5 test groups. The ANOVA (Table II) showed that
1 or more of the conditions were significantly different
from each other (P,.001). The Tukey test confirmed
that the mean fracture resistance for the control group
was significantly greater than for the 0-mm group, and
fracture resistance for the 3-mm group was significantly
greater than for the 0-mm and 1-mm groups (Table I).
When the mode of failure was evaluated, all failures in
the control group occurred due to root fracture, and
all failures in the 0-mm group occurred due to core fracture. As for the other groups, the majority of failures occurred due to crown cementation failure (Table III).

DISCUSSION
The hypotheses that there was a significant difference
in the effect of remaining coronal tooth structure on the
fracture resistance of endodontically treated teeth and a
significant difference between the types of fractures and
the type of post system used were accepted. Core fabrication using prefabricated posts and composite resin is a
viable technique for endodontically treated teeth.10-12
Fracture of the composite resin core when occlusal force
is applied may occur as protection of the supporting
root.14
This study showed that increasing ferrule length significantly increased the fracture resistance of endodontically treated teeth restored with prefabricated posts and
cores. However, it is important to note that the forces
responsible for failure in this study were considerably
higher than the maximal physiologic forces acting on
the teeth intraorally.27 Lyons and Baxendale 27 observed
that the mean force applied on a maxillary canine
was 215 N. In the presence of parafunctional loading,
the authors noted that this force increased to 254.8 N,
and the maximum forces were between 343 and
362.6 N.
It was observed that the control group presented significantly higher fracture resistance when compared
JANUARY 2006

310.7285 6.568228 .000298

MS, Mean square.

Table III. Types of failure (number and percentage of teeth)

Groups with same superscripted letters were not significantly different at


P,.05 (Tukey test).

groups were statistically different from the others. All


testing was done with alpha equal to .05.

MS
error

Location of failure

Groups

Resin
composite
only

Root only

Control
0 mm
1 mm
2 mm
3 mm
Total

10 (100%)
2 (20%)

12 (24%)

10 (100%)

10 (20%)

Crown
cementation
failure

7 (70%)
6 (60%)

13 (26%)

Coronal
structure

1
4
10
15

(10%)
(40%)
(100%)
(30%)

with the 0-mm ferrule group, and the 3-mm ferrule


group showed significantly higher fracture resistance
when compared with the 0-mm and 1-mm ferrule
groups. These findings are believed to be related to
the higher strength of the nickel-chromium alloy, the
higher modulus of elasticity,13 and the larger amounts
of coronal tooth structure. Furthermore, the size and
shape of the composite resin matrix particles account
for 66% of its volume.15 This higher quantity of inorganic particles corresponds to the maximum resistance
of compressive load, surface hardness, and wear resistance.5,15 The results of this study are in agreement
with other studies in which the authors concluded that
composite resin fracture can occur at a lower force
than that required to yield root fracture.16
The results of this study indicate that the presence of
remaining coronal structure did influence the fracture
resistance of the teeth. The findings of the present study
are in agreement with Sorensen and Engelman,8 who
found that 1 mm of remaining coronal tooth structure
was able to resist compressive load. In another study,
Sorensen20 showed that 1.0 mm of remaining coronal
tooth structure nearly doubled the fracture resistance of
endodontically treated teeth. Other authors8,18-20,23,24
concurred that fracture resistance was best for test specimens with the longest ferrules. The most common cause
of failure when using the direct technique (prefabricated
post and composite resin) was fracture of the restorative
material, and when the cast post and core was used, the
most common failure was the fracture of the root,14 as
observed in the present study (Table III).
This investigation demonstrated that roots restored
by individual cast posts exhibited higher fracture force
resistance than those restored by a prefabricated post
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THE JOURNAL OF PROSTHETIC DENTISTRY

and composite resin core. Despite its lower resistance,


the technique using prefabricated posts and composite
resin may be appropriate because there were no root
fractures. Hence, the direct method appeared to protect
the tooth structure.14
The limitations of this study include the use of finger
pressure to maintain the posts in position, which did
not provide a standardized loading force. This was an
in vitro study, which did not replicate oral conditions,
and a single load-to-fracture test was used to test the
fracture resistance of endodontically treated teeth. For
more meaningful results, future studies should incorporate thermal cycling of the specimens and fatigue
loading.

CONCLUSION
Within the limits of this study, the following conclusions were drawn:
1. Increasing ferrule length significantly (P,.05) increased the fracture resistance of endodontically treated
teeth restored with prefabricated posts and cores.
2. The 3-mm ferrule group showed significantly higher
fracture resistance (P,.05) when compared with the 0mm and 1-mm ferrule groups.
3. The presence of 2 mm of ferrule length significantly
increased (P,.05) the resistance of endodontically treated teeth restored with a prefabricated post and core
when compared with teeth without a ferrule.
4. The group restored with prefabricated post and composite resin core showed crown cementation failure before fracture of the root occurred. By contrast, the
specimens restored with cast post and core typically
showed fracture of the root.
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