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Warren I.

Libman, DDS, MSD'

Load Fatigue of Teeth Restored With Cast Posts and Cores and Complete Crowns

jack I. Nicholls,

PhD*'

Department of Restorative Dentistry School of Dentistry University of Washington Seattle, Washington

Twenty-five extracted human central incisors were divided into five groups and prepared for complete cast crowns. Test teeth had cast dowel cores fabricated with the ferrule height varying from 0.5 to 2.0 mm in 0.5-mm increments. The five control leeth did not have cast dowel cores. A 4.0-kg load was applied to each of the restored teeth at an angle of 135 degrees to the long axis of each tooth. This load was applied cyclically at a rate of 72 cycles per minute. The load application point was predetermined by a waxing jig that was used to wax all crowns. The primary variable was the ferrule length. The independent variable was the number of load cycles required to create preliminary failure. Preliminary failure was defined here as the loss of the sealing cement layer between crown and tooth. An electrical resistance strain gauge was used to provide evidence of preliminary failure. The results of this study showed that the 0.5 mm and 1,0 mm ferrule lengths failed at a significantly lower number of cycles than the 1.5 mm and 2.0 mm ferrule lengths and control teeth. Int J Proithodont I995;8:l 35-16!.

or fracturing of a material caused by repeated cyclic or applied loads below the yield limit.' Intraoral occlusal forces create this dynamic repetitive loading; thus, instead of a monotonie static load to fracture, it would be more clinically relevant to test specimens under a physiologic fatigue load. Fatigue life is a term used explicitly in fatigue literature to define the number of load cycles required to fail a specimen for a given applied load. In this research, fatigue life refers to a preliminary failure condition as opposed to complete fracture of the specimen. This preliminary failure is defined as the point at which a failure of the luting cement occurs that c l i n i c a l l y w i l l result in microleakage between the crown and the tooth,'" Such microleakage may eventually be manifested as recurrent caries, loss of retention, fractured posts, or complete dislodgment of the crown and 'Acting Assistant Professor. foundation restoration." " "Professor. This research investigated maxillary central incisors restored with cast posts and cores and Reprint requests: Dr ack I. Nicholls, Department of Restorative Dentistry, 5choo! of Dentistry SM-56, University of Washington. complete cast crowns. Four different ferrule lengths were investigated: 0.5 mm, 1.0 mm, 1.5 mm and Seattle, Washington 9B195.

esearch has clearly disputed the belief that foundation restorations reinforce endodontically treated teeth.'"* It has been suggested, however, that they provide a replacement for lost tootb structure to increase the retention and resistance form of a complete crown preparation.'^ Various foundation materials and techniques have been directly tested for retention and resistance to fracture. Clinically, however, the differences are of limited significance, since foundations are often covered by crowns that have been shown to negate these differences.'-^ The marginal area of a complete crown when extended onto the tooth structure beyond these foundation materials creates a ferrule. The ferrule Is defined as a metal band or ring used to fit the root or crown of a tooth.' Fatigue is tbe breaking

^I.; B, Number 2, 1995

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The Iniernaiional iournal of Prosthodonlii

Load Fstigue ol Cast Posts ^ Cores and Complete Caii Crowns

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2.0 mm. Preliminary failure defined the completion of each test. The controls were central incisors with complete cast crowns, without posts and cores.

Materials and Methods


Test Croups

Twenty-five extracted human maxillary central incisors were used in this study. These teeth were selected on the basis of lack of cracks, fractures or caries in the cervical area or root. The teeth were kept hydrated in room temperature distilled water prior to the study, and were wrapped in a wet gauze during tooth preparation. All fatigue testing was carried out with the teeth immersed in roomtemperature water. The teeth were randomly divided into five groups of five teeth each: Control, No cast post and core, restored with complete cast crowns. Croup 1. Restored with cast posts and cores and complete cast crowns with a 0.5-mm ferrule. Group 2. Restored with cast posts and cores and complete cast crowns with a 1.0-mm ferrule. Group 3. Restored with cast posts and cores and complete cast crowns with a 1.5-mm ferrule. Group 4. Restored with cast posts and cores and complete cast crowns with a 2,0-mm ferrule. Figure 1 shows these five groups diagrammatically.
Post and Cores Fabrication

All teeth in the four experimental groups had the coronal section removed level with the proximal CFJ, using a supercoarse diamond instrument (Brasseler USA, Savannah, GA) and copious irrigation. This prepared surface was further refined using wet 600 grit abrasive paper creating a planar surface perpendicular to the long axis ofthe root. The canal space was then prepared to a depth of 8 mm from the occlusal flat prepared surface to a final diameter of 0.05 inches (1.25 mm) using twist drills (Goitene/Whaledent, Mahwah, N|). An antirotational notch measuring 1.0 mm occlusoapically and 1.0 mm buccolingually was placed in the top flat surface on the lingual of the canal space preparation. The sharp junction between the top flat surface and the canal preparation was beveled with a green stone (Shofu, Menlo Park, CA). Three retentive notches were placed in the external root surface of each tooth to hold the tooth firmly in the holder during fatigue testing. Each tooth was

attached to a surveyor rod and lowered into the center of a machined aluminum cylinder which acted as the holder. The center of the post space was parallel to the axis of the machined cylinder. All teeth were embedded to a specific depth in their individual aluminum cylinders and retained with autopolymerizing resin (Duralay, Reliance, Worth, IL). Teeth were positioned with the crown margin 2.5 mm above the resin surface. A 1.25-mm plastic burnout pattern (Goltene/ Whaledent) was inserted into the 8-mm prepared canal space and a custom post and core pattern was constructed using autopolymerizing resin (GC Pattern Resin, GC America, Scottsdale, AZ). The teeth with the foundation restorations in place were then prepared for complete crowns using a coarse diamond instrument (Brasseler 6847/016). The preparation was refined under lOX magnification using a Brasseler 8847/016 fine diamond. The control teeth which had no foundation restoration, had a preparation height of 6.0 mm. The core portion of the post and core restoration on all experirnental teeth was 6.0 mm in height. On the experimental teeth the preparation finish lines were located 0.5 mm, 1.0 mm, 1.5 mm, and 2,0 mm apical to the core, giving preparation heights of 6.5 mm, 7.0 mm, 7.5 mm, and 8.0 mm, respectively. It should be noted here that providing a ferrule length increase for the tooth with a questionable ferrule may be achieved in one of two ways: (1> by periodontai crown lengthening, or (2) by orthodontic extrusion. Since crown lengthening seems to be the more commonly used procedure, this was used in this study. In doing so, however, the cast crowns increased in occlusocervical dimension with increasing ferrule length. The finish lines were circumferential shoulders 1.0 mm in width. The ferrule height was measured at eight locations around the periphery of the preparation during the refining procedure. All measurements were made with a dial caliper having an accuracy of 0.005 mm and measured using 10X magnification. The ferrule was measured at eight locations around the preparation, and an experimental accuracy of 0.05 mm obtained. The patterns were invested (Complete, JF Jelenko. Armonk, NY) and cast (Midigold Hard, Ivoclar/Williams, Buffalo, NY). The castings were then inspected under 20X magnification and adjusted to assure a passive fit. The cast dowel cores were then airborne particle abraded using 25 \irr\ aluminum oxide under 3 kg/cm' pressure and luted under finger pressure using zinc phosphate cement (Fleck's, Mizzy, Cherry Hill, NJ) mixed according to manufacturer's directions.

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Load Fatigue o Cssl Posts & Cotes a ntl Complete Cast Crowns

Control

Group 1

Group 2

Group 3

Group 4

Fig 1

Diagrammatic representation of the four test groups and the control group.

Cast Crown Fabrication Impressions of the final tooth preparations were made using a polyether impression material (Impregum, ESPE/Premier. Norristown, PA) and poured in Type IV dental stone (Fujirock, CC America), Two coats of die spacer (PDQ, Whip Mix, Louisville, KY) were applied to the dies, 'vVax copings (Maves #3 Inlay wax, Maves, Cleveland, OH) were fabricated on the dies and were transferred to the corresponding test specimens, which were positioned in a custom waxing jig (Fig 2). This waxing jig provided a standardized location or notch for the gold crown where the fatigue load was to be applied. This notch was located 1,0 mm incisai to the incisai edge of the core (see Fig 1). After waxing the notch location, each pattern was transferred back to the appropriate die, and the crown contours were completed, invested, and cast. Following casting and devesting, the crowns were inspected under 20x magnification for fit. When fit had been ascertained, the internal of the crowns was airborne particle abraded using 25 |jm aluminum oxide under 3.0 kg/cm- pressure. The crowns were cemented to the teeth wilh zinc phosphate cement, mixed according to manufacturer's directions. During tbe cementing procedure, each crown was held in place for 10 minutes under a 10- kg load.

Fig 2 Waxing ig showing notch where fatigue load was applied.

Tooth Dimensions Prior to iuting of the post and core, the buccolingual dimensions of each tooth at the crown finish lines were measured and recorded. Fatigue Loading Device The fatigue loading device was designed and fabricated at the University of Washington, and has been previously described,'' In keeping with the

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Definition of Preliminary Failure Preliminary failure was defined as the propagation of a crack in or around the luting cement layer. This crack was initiated at the lingual margin of tbe crown and propagated up tbe lingual axial wall. From a feasibility study, it was found that the existence of a crack and the micromovement of the cast crown relative to the margin was not discernible to the unaided eye. Propagation of this crack was visually observable in terms of the output on a model 455V Gould Chart Recorder {Clevite Corporation, Cleveland, OH) monitoring the strain gauge output. Measurement of Preliminary Failure The strain gauge on the lingual margin of the tooth/crown interface was connected as one arm of a Wheatstone Bridge circuit. According to the mathematics of the Wheatstone Bridge, tbe voltage output of this bridge is proportional to the movement of the lingual margin of the crown with respect to the finish line. This output voltage was recorded on a Gould Chart Recorder {Clevite Corporation), The tracing on this chart recorder depicted the relative micro-movement between the lingual margin of the crown and the finish line. Initially, the recorded amplitude was small and regular, with the tracing returning to zero when the tooth was unloaded. This indicated that the movement of the cast crown was elastic and that no crack had formed in the cement. Once a crack in the cement layer had formed, the amplitude of the tracing on the Gould chart recorder increased. Finally, the movement of the crown margin reached a magnitude that was beyond the range of the strain gauge, A diagrammatic representation of the strain gauge output at preliminary failure is shown in Fig 4, Verification of a Failure Crack in the Cement Layer The failed teeth were examined under 20X magnification, but no visible evidence of the existence of a crack was seen. Verification of this crack was obvious when a drop of water was placed on the lingual margin and intermittent pressure was applied to the crown while stabilizing the aluminum cylinder holder. Water was seen to pump in and out between the tooth finish line and lingual crown margin, A visual method of indicating the extent of the crack in the zinc phosphate cement was provided

Fig 3 Strain gauge on lingual surface of a test tooth.

loading conditions applied in vivo, the teeth used in this study vi'ere subjected to a fatigue load applied at an angle of 135 degrees to the long axis of the tooth," A 4-kg load was applied to the loading notch on each of the test crowns at a frequency of 72 cycles per minute." This load is within the range of physiological masticatory forces,"" All test and control teeth were immersed in a roomtemperature water bath during fatigue loading.
Strain Gauges

The strain gauges (EA-06-062AP 120, MicroMeasurements Division of Measurements Group, Raleigh, NC) had an internal electrical resistance of 120 ohms, and had a grid size of 0,062 inches {1,6 mm). The lingual crown/tooth interface was lightly ground with a diamond disk to create a flat surface and airborne particle abraded using 25 \rr\ aluminum oxide at a pressure of 3 kg/cm'. This surface was then cleaned with acetone, and a strain gauge was cemented to place using M-Bond strain gauge cement IMicro-MeasurementsI ensuring that the strain gauge grid was cemented over the tooth/crown interface. Following cementation, wires were soldered to the strain gauge terminals {Fig 3), and the strain gauge was completely covered with impression tray adhesive {Mirror 3, Kerr Manufacturing, Romulus, Mil to ensure exclusion of water during fatigue testing.

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Load FaligLe of Cast Posts & Cores and Complete Cast Cri

Strain gauge output Crack formation in cement

Cyclic load application

Fig 4 Ttieoretical diagram ot strain gauge output at preliminary failure.

by immersing the test teeth in black ink Pelikan Drawing Ink A, Pelikan AC, Germany) for 12 hours, then allowing the ink to dry for 6 hours. Following this, the crowns were sectioned in the mesiodistal plane with a carborundum disk (National Keystone, Cherry Hill, NJ|. The crown was then separated from the tooth, and the microleakage pattern observed but not quantified.
Statistical Analysis

Table 1 Number of Cycles to Failure


Group number Ferrule length (mm) Mean Standard deviation Statistical subsets""

1 2 3 4
Control

0.5 1.0 15 20 -

113
1140 71,651 60,045 91,208

83 665
53,590 26,604 49,891

'Five samples in eacii group. 'Rool fractured occurred prior to preliminary faiijre in one sample. '"Vertical lines indicate subsets ttiat are significantly different

lP<.05|. The independent variable recorded was the number of load cycles to preliminary failure. This variable was subjected to a one-way ANOVA, with the Student-Newman-Keuls test used to define significant subsets at the 95% confidence level. Results Table 1 shows the number of load fatigue cycles required to create preliminary failure for each test group- This table also contains the results of the statistical analysis, with statistical subsets defined by the vertical bars. These results are also shown in bar graph form in Fig 5. The one-way ANOVA test revealed that Croups 1 and 2 were significantly different from Groups 3, 4, and tbe control group (P< .05). It should be noted here that one sample in the control group exhibited root fracture prior to preliminary failure. Thus, only four samples for this group were evaluated in the statistical analysis.

r
o Ferrule length (mm Fig 5

,. i

Number of load cycles to create preliminary failure.

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Load FatiUe ol Casi Posts S, Cores and Complte Cnt Cr.

Fig 6

Microleakage between the crown ferrule and tooth.

Fig 7

ivlicroleakage pattern showing leakage along the post.

Microleakage Evaluation In all test groups, ink penetration occurred between the crown margin and lingual tooth finish line, up the ferrule, and into the tooth-core interface (Fig 61. In some specimens there was evidence of microleakage in the coronal portion of the post space (Fig 7). In no instance was ink observed between the crown and core. Discussion Earlier studies adopted a 2-mm ferrule length as being necessary for long-term clinical success of endodontically treated teeth.'"" For the conditions applied in this study, the results suggest that the minimum ferrule length for a central incisor should be 1.5 mm, since there was a significant increase in the number of load cycles to preliminary failure when the ferrule length was increased from 1.0 mm to 1.5 (Table 11. The number of cycles to preliminary failure was correlated with buccolingual dimensions of the test teeth. No significant correlation was found. There was an unexpected drop in the number of cycles to preiiminary failure when the ferrule length was increased from 1.5 to 2.0 mm. Although not significant, this drop may be explained by the greater crown height associated with the 2.0 mm ferrule that introdLtced a greater bending moment or dislodging moment on the crown. Preliminary failure did occur for the control group even though the preparations were entirely on tooth structure. The complete crown preparation of the central incisor provides minimal resistance form when loaded from the lingual (Fig 1|. Thus, crown disiodgment is possible for this restoration.

Tbe microleakage evaluation showed leakage patterns invading the ferrule, and progressing into the tooth-core junction and the post space. These observations are consistent with clinical findings of caries at the tooth-core junction, and fractured posts with the core and crown being dislodged as a single unit.""" As with many in vitro studies, it is difficult to extrapolate these results directly to the clinical situation. The elasticity of the periodontal ligament was not duplicated, and the ferrule height was a constant height around the periphery of the teeth. Teeth are generally prepared, however, with their finish lines following the coronal extension of the gingival tissue level interproximally. Also, the ferrule height usually varies around the circumference of the tooth. In light of the results of this study, one should certainly consider some modification in treatment plan when a tooth presents with a ferrule of less than 1.5 mm. This becomes even more important if the final restoration will be subjected to a possible load increase, as a fixed partial denture abutment, for example, or an abutment for a distal extension base removable partial denture. Periodontal crown lengthening, or orthodontic extrusion, may be indicated to increase the ferrule height.

Conclusion Twenty-five central incisors were restored with cast posts and cores and complete crowns, and subjected to a cyclically varying (fatigue) 4-kg load. These twenty-five teeth were divided into four test groups and one control group according to the ferrule length of the crown. The test groups had ferrule lengths of 0,5 mm, 1.0 mm, 1.5 mm

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l.o.id F.KiKiie ct" Cast Posts , Cores and Complete Casi Crowns

and 2.0 mm. The control group had no cast dowel cores. Loading of all specimens was continued until preliminary failure occurred, when movement between the crown and the tooth increased as a result of crack formation either la> at the cement/crown interface, (b) at the cement/tooth interface, or (c) in the cement. From the results of this study the following conclusion may be made. When the ferrule length was greater than or equal to 1.5 mm, a significant increase in the number of load cycles to preliminary failure was recorded when compared to crowns having a ferrule length less than 1.5 mm.

9. The Glossary of Prosthodontic Terms, ed 6. i Prosthet Dent 1994;71[l):72. 10. Freeman MA, Nicholls | l , Kydd W, Harrington GW. Leakage associated with load fatigue induced preliminary failure of full crowns over three post and core systems. | Endodont |in press). 11. Pashley DH. Clinical considerations of microleakage. I Endodont 1990:1 6|2):70-7? 12. Lewis R, Smith BC A clinical survey of failed post retained crowns. Br Dent 1 988;l65(3):95-97. I 3. Sorensen |, Engelman M. Ferrule design and fracture resistance of endodonticaliy treated teeth. | Prosthet Dent 1990;63:529-536. 14. Fissore B, Nicholls | l , Yuodelis RA. Load fatigue of teeth restored by a dentin bonding agenl and a posterioi composite i-esin. I Prosihet Dent 1992;6S:!iO-e5. Reitz PV, Aoki H, Yoshloka M, Uehara |, Kuhota Y. A cephalometric study of tooth position as related to facial structure in profiles oi human beings: A comparison of Japanese (Oriental! and American [Caucasian] adults. | Prosthet Dent 1972:29:157-166. Bates JF, Stafford GO, Harrison A. Masticatory function A review oi the literature. II. Speed of movement oi the mandible, rate of chewing and forces developed in chewing. I Oral Rehab 1975,2.349-361. Helkimo , Ingervall B. Bite force and functional state of the masticatory system m young men. Swed Dent J 1978:2:167-175. Anderson D]. Measurement of stress in mastication. 1. | Dent Res 1956;35:664-670. Anderson DJ. Measurement of stress in mastication. II. J DenlRes 1956:35:671-673. Trabert KC, Cooney IP. The endodontically treated tooth: Restorative concepts and techniques. Dent Clin North Am 1984:28:923-951. Rosen H, Part I da-Rivera M. latrogenic fracture of roots reinforced with a cervical collar. Oper Dent 1986;n(2):46-50. Barkhordar R, Radke R, Abbasi |. Effect of metal collars on resistance of endodontically treated teeth to root fracture. J Prosthet Dent 1989,61:676-678.

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