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
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
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preparation. Conversely it has been shown that 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

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

* 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.

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maximum retention for coronal reconstruction especially in non circular canals . Cast post core
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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.

closely reproduces morphology of root canal space and may be more conservative option with minimal dentin removal. Preference of the cast post core
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system is derived in part from incorporation of encircling collar of metal (ferrule) hypothesized to protect the tooth from wedging stresses. ' A key
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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,

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.

Table 1-Study Materials

SI. NO 1 2 3 MATERIAL Type 11 gold alloy RelyX ARC resin cement Zinc phosphate cement 3 M Dental products HARVARD Germany MANUFACTURER COMPOSITION 18 karat gold Methyl metacrylate, TEG0MA, Bis- GMA, Zirconia fillers, photoinitiators Powder: 90 % zinc oxide Liquid: 69% buffered phosphoric acid Aluniniumphosphate, aluminium, zinc 4 INLAY WAX medium GC ASIA

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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.

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 and0.5 mm on lingual aspect. The preparation convergence angle was standardized using handpiece mounted on a dental surveyor

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

Specimens divided in 6 groups

created at the lingual surface of tooth 3 mm below

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incisal edge to create a standard loading point. Casting was done using induction casting machine (DEGUSA) with 18 K gold alloy.

MOKSHA NAYAK, KRISHNA PRASADA, DHEERAJ SHETTY

The teeth were then stored in saline solution for 3 days prior to fracture testing.

Fracture Testing
Specimens were tested using universal testing machine (INSTRON 4206) set to deliver an increasing load until failure .The crosshead speed of 2.5 mm/min & the load was applied at an angle of 135 to long axis of tooth. Compressive load was applied 3 mm from incisal edge and the force applied was recorded in kilograms.

Cementation of Post
All the 60 specimens had their canal walls cleaned with 15%EDTA followed by irrigation with saline which were then dried using absorbent paper points. For teeth in group (1.2& 5) Zinc phosphate cement (HARVARD) was mixed to luting consistency and then inserted into canal using 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 unit to ensure the cement was cured completely.

Figure 1. Specimen mounted in the INSTRON universal testing machine

Table 2. Comparison of the mean fracture load among the 6 groups using analysis of variance using ANOVA
N Uniform Zn phosphate cement { Group 1) Non uniform Zn Phosphate cement ( Group2) Uniform Resin cement { Group 3} Non uniform resin cement ( Group 4) Control Zn phosphate cement ( Group 5) Control Resin cement ( Group 6)
a. F=126.163 p< O.001 vhs

Std. Deviation 45.9000 27.0000 51.0000 30.3000 17.8000 22.3000 4.53260 2.05480 4.71405 3.71334 2.74064 3.88873

Minimum 38.00 24.00 42.00 25.00 14.00 18.00

Maximum 52.00 30.00 58.00 36.00 22.00 28.00

10 10 10 10 10 10

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

Bar graph-showing Comparison of Mean compressive load among the six groups

RESULTS
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
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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 &
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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 guttapercha 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
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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 45 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

ENDODONTOLOGY
endodontically treated tooth.

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.

the effect of core ferrule on fracture resistance on

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
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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
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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

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
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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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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.

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