Fracture strength after dynamic loading of endodontically treated teeth restored with different post-and-core systems

Guido Heydecke, DDS, Dr Med Dent,a Frank Butz, DDS, Dr Med Dent,b Amr Hussein, DDS,c and Jrg R. Strub, DDS, Dr Med Dent, PhDd School of Dentistry, University of Michigan, Ann Arbor, Mich.; and School of Dentistry, Albert-Ludwigs University, Freiburg, Germany Statement of problem. Prefabricated metal and ceramic posts can be used with direct or indirect cores
as an alternative to the conventional cast post and core. It is unclear how the fracture strength of zirconia posts with composite or ceramic cores and titanium posts with composite cores compares to the fracture strength of gold posts and cores after dynamic loading. Purpose. This study compared the fracture strength of endodontically treated, crowned maxillary incisors with limited ferrule length and different post-and-core systems after fatigue loading. Material and methods. Sixty-four caries-free, human maxillary central incisors were divided into 4 groups. After root canal treatment, Group 1 was restored with titanium posts and composite cores, Group 2 with zirconia posts and composite cores, and Group 3 with zirconia posts and heat-pressed ceramic cores. Teeth restored with cast-on gold posts and cores served as the controls (Group 4). Teeth were prepared with a circumferential shoulder including a 1 to 2 mm ferrule; all posts were cemented with an adhesive resin cement, restored with complete-coverage crowns, and exposed to 1.2 million load cycles (30 N) in a computer-controlled chewing simulator. Simultaneous thermocycling between 5C and 55C was applied for 60 seconds with an intermediate pause of 12 seconds. All specimens that did not fracture during dynamic loading were loaded until fracture in a universal testing machine at a crosshead speed of 1.5 mm/min; loads were applied at an angle of 130 degrees at the incisal edge. Fracture loads (N) and modes (repairable or catastrophic) were recorded. The Kruskal-Wallis test was used to compare fracture loads among the 4 test groups. Analyses were conducted both with and without the specimens that failed during the chewing simulation. A Fisher exact test was performed to detect group differences in fracture modes. A significance level of P<.05 was used for all comparisons. Results. The following survival rates were recorded after the chewing simulation: 93.8% (Group 1), 93.8% (Group 2), 100% (Group 3), and 87.5% (Group 4). The median fracture strengths for Groups 1 to 4 were 450 N, 503 N, 521 N, and 408 N, respectively. No significant differences were detected among the groups. The use of zirconia posts resulted in a nonsignificant lower number of catastrophic root fractures. Conclusion. Within the limitations of this study, the results suggest that zirconia posts with ceramic cores can be recommended as an alternative to cast posts and cores. If a chairside procedure is preferred, zirconia or titanium posts with composite cores can be used. Clinical trials are required to verify these in vitro results. (J Prosthet Dent 2002;87:438-45.)

CLINICAL IMPLICATIONS
The results of this in vitro study suggest that zirconia posts with heat-pressed ceramic cores could be used as an alternative to metal posts and cores, and that titanium posts with composite cores could be used as a chairside alternative to cast posts and cores without a loss in the fracture resistance of maxillary anterior teeth.

aVisiting

Assistant Professor, Department of Biologic and Materials Sciences, University of Michigan School of Dentistry. Assistant Professor, Department of Prosthodontics, Albert-Ludwigs University School of Dentristry. bAssistant Professor, Department of Prosthodontics, Albert-Ludwigs University School of Dentistry. cPostgraduate student, Department of Prosthodontics, Albert Ludwigs University School of Dentistry. dProfessor and Chairman, Department of Prosthodontics; Dean, Albert Ludwigs University School of Dentistry. 438 THE JOURNAL OF PROSTHETIC DENTISTRY

n prosthodontic practice, the task of restoring endodontically treated teeth is encountered almost daily. Leempoel et al1 evaluated a large sample of teeth with single crown restorations and found that 39% were non-vital and had received some type of post restoration. Many abutment teeth planned for fixed prosthodontic treatment require post-and-core
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buildups because of extensive structural defects resulting from decay, trauma, or prior restoration. In most situations, severely compromised teeth are permanently restored with complete-coverage crowns to restore function and esthetics. The amount of remaining tooth structure dictates the type of core buildup that can be used in pulpless teeth. When there is minimal loss of structure, posts and cores are not necessary.2 The clinician often finds, however, that horizontal loss of the clinical crown has occurred and that little ferrule can be created in the remaining tooth structure.3,4 In these situations, there are few alternatives to restoration with a post-and-core buildup.5 The choice of an appropriate restoration for endodontically treated teeth is guided by strength and esthetics. The cast gold post and core has been regarded as the gold standard in post-and-core restorations due to its superior success rate.6,7 Alternatives to cast posts and cores have been developed. The use of prefabricated posts and custom-made buildups with amalgam or composite simplifies the restorative procedure because all steps can be completed chairside, and fair clinical success can be expected.8-10 New tooth colored posts have improved the esthetics of teeth restored with posts and cores.11-13 In addition, zirconia ceramic can offers superior strength compared to other post materials.11,14,15 The use of composite as a core material has also enhanced the ability to reproduce the shade and translucency of natural teeth. The restoration of teeth with adhesively cemented internal restorations offers improved mechanical stability over cemented restorations.16 As an alternative to composite cores bonded to zirconia posts,17 a new technique allows the addition of a heat-pressed ceramic core to achieve tooth-colored indirect posts and cores.18 Controversial results have been reported from in vitro research that compared prefabricated and individually cast posts and cores. Cast post-and-core assemblies were reported to yield higher fracture strengths than direct buildups with prefabricated posts and amalgam.19 However, it was concluded that the load-bearing capacity of the direct cores was sufficient to withstand physiological forces.19 Others reported that composite and amalgam direct cores supported by a prefabricated parallel dowel exhibited fracture resistance superior to that of a cast gold core.20,21 Direct cores made from composite with prefabricated posts and cast posts and cores also have been tested under fatigue loading conditions. The direct posts and cores withstood a higher number of load cycles and demonstrated higher fracture strengths than cast posts and cores.20,22,23 Comparison of results across studies is difficult, however, because complete-coverage crowns were not used consistently. A recent study demonstrated the suitability of titanium posts with composite cores or zirconia posts with ceramic cores for the restoration of nonvital teeth with partial
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loss of the clinical crown. Both restorative options exhibited characteristics comparable to those of cast posts and cores.14 Clinical comparisons of the techniques described above are not available. The value of static testing in simulating restoration failure has been questioned, and cyclic loading has been suggested as an alternative.24 Thermomechanical fatigue loading simulates clinical conditions while reducing costs and evaluation time.25-27 A computer-controlled chewing simulator was selected for this investigation. The purpose of this investigation was to compare direct composite cores used with either titanium or zirconia posts for anchorage to heat-pressed ceramic cores used in combination with zirconia posts. A commercially available type III gold alloy core cast on a prefabricated gold post was used as the control. Care was taken to use industrially prefabricated posts with identical geometries and diameters. The parameters chosen for evaluation were the survival rate, fracture strength, and mode of failure after simulated chewing of post-and-core restorations. The hypothesis was that there would be no difference in the fracture strengths of the 4 test groups after 1.2 million cycles of thermomechanical fatigue loading.

MATERIAL AND METHODS

Sixty-four human maxillary central incisors were obtained directly after extraction and stored in 0.1% thymol solution during the course of the study. Teeth with cracks, caries, restorations, and/or roots shorter than 10 mm were discarded. Teeth were selected for the study if their length was within 1 mm of a mean value of 23 mm.28 The teeth were randomly divided into 4 groups of 16 teeth each (Table I). Endodontic treatment was performed through stepwise filing with reamers and hedstrom files to International Standards Organization (ISO) size 60. After being intermittently rinsed with 2.5% sodium hypochloride, all roots were obturated with laterally condensed gutta-percha (VDW, Munich, Germany) and a resin sealer (AH plus; DeTrey, Konstanz, Germany). With the use of a diamond bur in a highspeed handpiece, the teeth were decoronated 1 mm coronal to the most incisal point of the approximal cemento-enamel junction (CEJ) and perpendicular to the long axis of the tooth under continuous water cooling. All teeth received 1.2 mm butt shoulder finish line preparations with the use of regular- and fine-grit parallel-sided, flat-end diamond burs (837KR314.012 and 8837KR314.012; KometBrasseler, Lemgo, Germany) in a high-speed handpiece. The preparations had a wall convergence of approximately 6 degrees. Gutta-percha was removed from the root canals with a peeso reamer, leaving 3 mm of root canal filling
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Fig. 1. Dimensions of tooth preparations and posts/cores were identical for 4 groups of specimens. Dentin ferrule was prepared circumferentially. Table I. Overview of posts and cores used in the 4 specimen groups
Group N Type of post Core Number of failed specimens Survival (%)

1 2 3 4 (control)

16 16 16 16

Titanium Zirconia Zirconia Gold

Composite Composite Heat-pressed ceramic Cast-on gold

1 1 0 2

93.8 93.8 100 87.5

Survival after 1.2 million cycles of fatigue loading is expressed as the percentage of specimens that survived the chewing simulation.

in the apical portion (Fig. 1). Subsequently, a tapered No. 2 drill (ISO 90) from the Komet ER post kit (Komet-Brasseler) was used to enlarge the root canals in preparation for endodontic post placement. The size and shape of the burs included in this kit correspond to posts that are made from different materials but industrially prefabricated to the same dimensions to ensure comparable adaptation.29 In test Group 1, titanium posts (ER 61L16; Komet) were used to create anchorage for composite cores. In Group 2, zirconia posts (Cerapost 232L12; Komet) were chosen. After posts were cut to a length 3 mm coronal to the preparation, their surfaces were air-particle abraded with 50 m aluminum oxide at 2.5 bar. The inner walls of the root canals were roughened with a diamond-surfaced instrument of the same diameter as the posts. All canals were preconditioned with a self-etching primer (ED-Primer; Kuraray, Osaka, Japan), and the posts were luted with a chemically polymerized resin cement (Panavia 21 Ex; Kuraray). To ensure isolation from air and prevent anaerobic setting, a viscous gel was applied (Oxyguard II; Kuraray). The post and tooth surfaces were cleaned, etched for 15 seconds with 35% phosphoric acid (Etching agent V; Kuraray), and primed (NewBond; Kuraray). Composite cores were built up (Clearfil Core; Kuraray) to yield an abutment height of 6 mm measured from the buccal CEJ. The total abutment height comprised 4 mm of core material and a dentin ferrule
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that measured 2 mm buccally and 1 mm proximally (Fig. 1). The core was then prepared so that it conformed to the existing preparation. In Group 3, zirconium dioxide posts were fitted as described above, and a core pattern was built up with autopolymerizing acrylic resin (Pattern Resin; GC Corp, Tokyo, Japan). The patterns were prepared to the desired shape with a high-speed handpiece and appropriate diamond burs according to the criteria described for Groups 1 and 2. The posts and core patterns were subsequently sprued and invested (IPS Empress Investment; Ivoclar, Schaan, Liechtenstein). After the burnout and preheating process, the core was heat-pressed from zirconia-enriched glass-ceramic (Empress-Cosmo; Ivoclar) at 900C and 5 bar.30 The investment was removed, all surfaces were carefully airabraded, and the posts and cores were luted (Panavia 21 Ex; Kuraray) in accordance with the procedure described above. In Group 4 (control), gold alloy cores were cast on prefabricated gold posts (ER-Heraplat 204 L12; Komet) for anchorage. Core patterns were added to the posts according to the dimensions specified above with autopolymerizing resin. The post/pattern assemblies were invested, and the cores were cast-on with a type III gold alloy (Pontor MPF; Mtalor, Stuttgart, Germany). After being cleaned and air-particle abraded, the posts and cores were luted (Panavia 21 Ex; Kuraray) (Table I).
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All preparations were finished with 1.2 mm butt shoulder preparations and a wall convergence of approximately 6 degrees. The finish line of each preparation followed the CEJ. With the use of a silicon stent, 64 single tooth incisor crowns of identical dimensions were waxed and cast in a base-metal alloy (Remanium; Mtalor). The crowns were luted with a glass-ionomer cement (Ketac-Cem; ESPE, Seefeld, Germany). A typical clinical model with a facio-lingual tooth inclination of 130 degrees and a mesio-distal angle of 2 degrees was chosen for fabrication of the test specimens.28,31 A silicone stent incorporating these angulations was used. To simulate a periodontal membrane, all roots were covered with a 0.1-mmthick layer of autopolymerizing silicone (Anti-Rutsch-Lack; Wenko, Wensselaer, Germany). The roots were blocked out with wax to a depth of 2 mm below the finish line to simulate the biologic width. After the removal of any excess silicone, the silicone stent was used to position the teeth in a specimen holder, which was filled with autopolymerizing acrylic resin (Technovit 4000; Kulzer, Wehrheim, Germany). All 16 specimens in each group were exposed to 1.2 million cycles of thermomechanical fatigue loading in a computer-controlled dual-axis chewing simulator (Willytec, Mnchen, Germany). This protocol simulated 5 years of clinical service26,27 (Fig. 2). The force was applied 3 mm below the incisal edge on the palatal surface of the crowns at a frequency of 1.3 Hz32 using a ceramic ball with 6-mm diameter (Steatite; Hoechst Ceramtec, Wunsiedel, Germany). A force of 30 N was chosen to simulate a load within the clinical range.32,33 During testing, all specimens were subjected to simultaneous thermocycling between 5C and 55C for 60 seconds each with an intermediate pause of 12 seconds, maintained by a thermostatically controlled liquid circulator (Haake, Karlsruhe, Germany). All specimens that did not fracture during the dynamic loading were loaded until fracture in a universal testing machine (Z010/TN2S; Zwick, Ulm, Germany) at a crosshead speed of 1.5 mm/min. Loads were applied at an angle of 130 degrees at the incisal edge; tin foil was used to ensure even stress distribution. Fracture loads and modes were recorded. Tooth fractures were classified as repairable and catastrophic failures. The Kruskal-Wallis test was used to compare fracture loads among the 4 groups after the static load test. Specimens that fractured during the chewing simulation and thus were not available for static testing were assigned a value of zero to account for their preliminary failure. Statistical analyses were conducted both with and without the failed specimens. Fractures were classified as restorable if located in the incisal third of the root and catastrophic if located below. A
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Fig. 2. Specimens were mounted in holder at angle of 130 degrees and biaxially loaded with ceramic ball.

Fisher exact was performed to detect group differences in fracture modes. A significance level of P<.05 was used for all comparisons.

RESULTS
Fractures that occurred during thermomechanical fatigue loading became apparent only upon removal of the specimens from the chewing simulator. For this reason, no accurate information could be obtained with regard to the number of cycles or time at which the specimens failed. One specimen in Group 1 (titanium/composite), 1 specimen in Group 2 (zirconia/composite), and 2 specimens in Group 4 (control; cast post and core) fractured during the chewing simulation. All Group 3 specimens remained intact. Overall survival rates were expressed as the percentage of surviving specimens after the chewing simulation (Table I). Mean fracture loads after static loading are presented in Figure 3, with specimens that failed during thermomechanical fatigue loading identified as outliers. The highest fracture strengths were observed in groups restored with zirconia posts. In Group 2 (zirconia posts/composite cores), a mean value of 503 N was recorded, and in Group 3 (zicronia posts/ceramic cores), a mean value of 521 N was recorded. Lower fracture strenths were recorded for titanium posts with composite cores (450 N; Group 1). Cast posts and cores exhibited the lowest strength values (408 N; Group 4). During the static testing of 1 cast post-andcore specimen, the data recording software ceased to operate. Consequently, only 15 values were included in the statistical evaluation of the control group. The Kruskal-Wallis test detected no significant difference in
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Fig. 3. Mean fracture loads and standard deviations (N) after static loading of specimens. Outliers with numerical value of zero represent specimens that fractured during fatigue loading phase of study.

Fig. 4. Locations and frequencies of fractures in 4 test groups. Fractures in incisal third of root were deemed repairable; fractures below were deemed catastrophic.

fracture strengths among the 4 groups (P=.0907), even when the failed specimens were excluded (P=.1717). The fracture patterns of all test groups are presented in Figure 4. The number of catastrophic fractures was higher in groups with metal post restorations. In Group 1 (titanium posts/composite cores), 3 fractures were located at mid-root or in the apical third; 13 repairable fractures occurred in the coronal third. A similar pattern was found in Group 4 (cast post and core), with 5 catastrophic and 11 repairable fractures.
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Eight catastrophic failures were recorded in Group 2 (zirconia posts/composite cores) and only 2 in Group 3 (zirconia posts/ceramic cores). A Fisher-exact test detected no significant differences in fracture patterns among the test groups (P=.36). The majority of fractures involved the lingual crown margins and extended to the incisal third of the buccal root surfaces. All composite cores were separated from their posts. While titanium posts and cast-on post and cores were either bent or dislodged from the root canals, all zirconia posts fractured.
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DISCUSSION
Clinical comparisons of the performance of cast posts and cores and direct buildups with prefabricated posts are scarce. Success rates of up to 87% have been reported for cast posts and cores after 6 years.6,7 Success rates for direct posts and cores range from 68% after 10 years to 92% after 8 years.7,9,10 New treatment options have become available since these studies were published. Kern et al,11 for example, have published preliminary, encouraging results on the use of zirconia posts for the esthetic restoration of nonvital teeth. In the case of substantial horizontal loss of the clinical crown, there is no restorative alternative to fabricating a post-and-core buildup.5,13 The current study attempted to compare the conventional metal post and core with newer restorative approaches. Industrially prefabricated cylindro-conical gold posts were selected for this investigation to avoid any inaccuracy that might have been resulted from the use of custom-made posts. Because a wedging effect has been associated with tapered posts,29,34 post shape was standardized across the test groups. With rigid post systems, fractures commonly occur in the apical half of the root.34 In the present study, one specimen each in Groups 1 (titanium posts/composite cores) and 2 (zirconia posts/composite cores) fractured during the cyclic loading test. More specimens in the control group (cast post and core) fractured during the chewing simulation. In a study by Ryther et al,35 a lower fracture resistance was reported for cast post and cores compared to completely cast units when the post unit alone was tested. It was suggested that the posts may have been weakened by the cast-on process. In the present study, no fractures of the prefabricated posts were observed. It has been reported that more rigid reconstructions are unable to absorb stress and are therefore susceptible to failure.12,13 The overall survival rates recorded in the present study are similar to those reported by Butz et al14 (cast post and core, 81%; titanium or zirconia posts/composite cores, 93.8%; zirconia posts/ceramic cores, 100%) and by Strub et al36 (zirconia posts/composite cores, 80%, zirconia posts/ceramic cores, 100%) but larger than those reported by Mannocci et al13 (zirconia posts/composite cores, approximately 45%). The greatest number of restorable fractures were recorded in Groups 2 and 3, which both included zirconia posts. This result may be attributable to the fact that zirconia posts had the highest modulus of elasticity among the post types tested. Higher modulus of elasticity results in less bending of the post/core unit under load; consequently, less stress is exerted on the tooth. This phenomenon also was reported in a previous investigation.14 Differences between the groups in
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the present study were not significant, in part due to the limited sample size. The zirconia/ceramic combination (Group 3) offered the additional advantage of improved esthetics due to its white color. The type of failure recorded in Groups 2 and 3 resembled the pattern found in a study that tested carbon-fiber posts.12 Carbon-fiber posts have a modulus of elasticity closer to dentin and lower than that of zirconia, titanium, and gold. The maximum fracture strength of carbon-fiber posts and cores has been reported as significantly lower than of cast posts and cores, but most fractures in the former are repairable.12,37 Fracture strength values from other studies are not comparable to the results of the present study because of differences in research design. Human teeth have been used successfully for the in vitro testing of post restorations in this and other studies.14,15,20,21,34 All teeth were prepared to an abutment height of 5 mm above the most incisal point of the CEJ, resulting in slightly different final tooth lengths.4,21 Because the post hole preparation ended 3 mm from the apex, variations in post lengths also resulted. Specimen differences were the result of anatomical variation and hand preparation, which replicates clinical reality. In the current study, all specimens were restored and tested with complete-coverage crowns to ensure standardization. The placement of a crown during endodontic restoration testing as been questioned, as this practice may obscure the effects of different buildup techniques.20,38 It is true that a crown creates a ferrule effect and different load distribution when placed over a core buildup if the margins encircle a sound dentin collar.3,4,34 However, testing post-andcore preparations without placement of a crown would not have reflected common clinical practice. If 50% or more of the coronal portion of the clinical crown is lost, direct core restorations with either titanium or zirconia posts are appropriate. With regard to strength, cast posts and cores offer no advantage over direct techniques.14 The lack of significant differences in fracture strengths among the test groups in the present study may be attributable, in part, to the magnitude of the standard deviations. The statistical procedure was designed to include specimens that failed during the chewing simulation. Because those specimens were assigned a fracture load of 0 N after 1.2 million cycles of simulated service, larger standard deviations resulted. Fracture load values reported in the literature for comparable restorative approaches typically were obtained on non-fatigued samples. The fracture strengths recorded in the present study appear to be comparable or slightly higher than those reported in other studies with a similar design.4,14 For one specimen in the control group, no fracture load value was obtained due to a malfunction of the
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data recording software. The aging and testing procedures were not repeated with a new tooth because this would have threatened the validity of the initial sampling and randomization process. The results of this study were based on a simulation of clinical parameters. The procedures were adopted from published recommendations on simulation of the clinical parameters of load,24,33 cycle frequency,32 and load angle.28,31 Thermocycling was performed to simulate moisture and temperature changes encountered intraorally. One shortcoming of the present study is that the number of cycles during the chewing simulation could not be recorded with the equipment used. In future studies, strain gauges could be used to detect preliminary failure of the restoration. Another limitation is that slight differences in post lengths may have influenced the results of the fracture strength test. Attempts were made to minimize this possibility. Given an average crown length of 10.5 mm for central incisors,28 the resulting post lengths and initial lengths of the teeth used varied within 1 mm. Meaningful results have been reported in other studies that involved a chewing simulation or fatigue loading of post-and-core restorations.14,22,23 Clinical trials are necessary to validate the results of these investigations as well as the present in vitro study.

7. 8. 9.

10. 11. 12. 13.

14.

15.

16. 17.

18.

19.

CONCLUSIONS
Within the limitations of this in vitro study, no significant differences in fracture strength or fracture patterns were detected among the 4 test groups. The following conclusions therefore can be drawn: 1. Zirconia posts with ceramic cores can be recommended as an esthetic alternative to cast posts and cores in the anterior region. 2. If a chairside procedure is preferred, zirconia or titanium posts with composite cores can be used as an alternative to cast posts and cores.
We gratefully acknowledge Komet (Gebr. Brasseler GmbH & Co KG, Lemgo, Germany) for donating the posts used in this study. We also wish to acknowledge the expertise of Mr Thomas Gerds, Department of Medical Biometry, Albert-Ludwigs University, for performing the statistical analysis and Peter Yaman, University of Michigan School of Dentistry, for his editorial help.
20. 21.

22.

23.

24. 25.

26.

27.

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34. Assif D, Bitenski A, Pilo R, Oren E. Effect of post design on resistance to fracture of endodontically treated teeth with complete crowns. J Prosthet Dent 1993;69:36-40. 35. Ryther JS, Leary JM, Aquilino SA, Diaz-Arnold AM. Evaluation of the fracture resistance of a wrought post compared with completely cast post and cores. J Prosthet Dent 1992;68:443-8. 36. Strub JR, Pontius O, Koutayas S. Survival rate and fracture strength of incisors restored with different post and core systems after exposure in the artificial mouth. J Oral Rehabil 2001;28:120-4. 37. Martinez-Insua A, da Silva L, Rilo B, Santana U. Comparison of the fracture resistances of pulpless teeth restored with a cast post and core or carbon-fiber post with a composite core. J Prosthet Dent 1998;80:52732. 38. Patel A, Gutteridge DL. An in vitro investigation of cast post and partial core design. J Dent 1996;24:281-7.

Reprint requests to: DR GUIDO HEYDECKE DEPARTMENT OF PROSTHODONTICS SCHOOL OF DENTISTRY ALBERT-LUDWIGS UNIVERSITY HUGSTETTER STR. 55 79106 FREIBURG, GERMANY FAX: (49)761-270-4925 E-MAIL: heydecke@umich.edu Copyright 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 + 0. 10/1/123849 doi:10.1067/mpr.2002.123849

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