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The Effect of Post Type and Length on the Fracture Resistance of Endodontically Treated Teeth

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The Effect of Post Type and Length on the Fracture Resistance of Endodontically Treated Teeth THE EFFECT OF POST TYPE AND LENGTH ON THE FRACTURE RESISTANCE OF ENDODONTICALLY TREATED TEETH By John Duncan McLaren, D.D.S. A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Restorative Dentistry The University of Michigan School of Dentistry Ann Arbor, MI 2003 Thesis Committee: Dr. Peter Yaman, D.D.S., M.S.; Chairman Dr. Joseph Dennison, D.D.S., M.S. Dr. Neville McDonald, D.D.S., M.S. Dr. Warren Wagner, M.S., Ph.D. DEDICATION This thesis is dedicated to my mentors throughout my educational experience and to my family whose unwavering support has always allowed me to strive toward the highest of goals. ii ACKNOWLEDGEMENTS Many thanks to the following people: Dr. Peter Yaman for his support as my thesis advisor and his wonderful mentorship. The lessons learned from you go well beyond dentistry. Dr. Joseph Dennison for his insight and research savvy. Your guidance has been most appreciated. Dr. Neville McDonald for his helpfulness. It has been a pleasure to have you serve on my thesis committee. Dr. Warren Wagner for his friendship and exquisite technical approach to solving problems. Your generosity to serve on my committee is highly valued. I look forward to many years of collaboration with you to improve dentistry. Ken Guire for his expert statistical assistance and analysis. Dr. Patricia Bauer for her help with endodontic procedures. Dr. Alberto Herrero for his assistance in mechanical testing of teeth. Your expertise and patience is greatly appreciated. Dr. John Powers and Dr. Huan Lu for their timely assistance in flexural modulus testing of posts. General Dentistry Clinic staff for their assistance and willingness to try new things throughout my residency. You all managed to effectively handle my many different techniques and materials. Bea Burgett, you are an awesome assistant and wonderful person. Dr. Marcela Newman for her direction and guidance in helping me to select this project. Your friendship and enthusiasm made my time in Grad Op special. My parents, John and Ning, for a lifetime of support and unconditional love. My loving grandmother and aunt whose generosity will not be forgotten. Dr. Gabriella Mantellini, Dr. Hana Al-Dohan, Dr. Scott Kooistra, and Dr. Charles McLaren. You all have been a remarkable group of friends and classmates and I look forward to twenty years from now seeing the great achievements you all have made. And finally a special heartfelt thanks to Scott and Charles for the years of solidarity, both inside and outside the clinic. You guys made the last three years memorable and worthwhile. iii TABLE OF CONTENTS TITLE PAGE…………………………………………………………………… i DEDICATION…………………………………………………………………... ii ACKNOWLEDGEMENTS……………………………………………………... iii TABLE OF CONTENTS………………………………………………………... iv LIST OF TABLES……………………………………………………………..... v LIST OF FIGURES……………………………………………………………… vi CHAPTER 1 BACKGROUND AND SIGNIFICANCE………..……………………………... 1 Objectives……..…………………………………………………………... 3 Hypotheses…..……………………………………………………………. 3 REVIEW OF THE LITERATURE……….……………………………............... 4 Clinical performance.……………………………………………………... 4 Microleakage…..…………………………………………………………. 6 Bonding..……………………………………………………………......... 7 Retention…….……………………………………………………………. 9 Post effect on remaining tooth……………………………………………. 18 Root reinforcement…...…………………………………………………… 19 Post removal……..……………………………………………………….. 22 Mechanical testing……..………………………………………………..... 22 REFERENCES…………………………………………………………………... 39 PRELIMINARY STUDY…...…………………………………………………... 43 CHAPTER 2 THE EFFECT OF POST TYPE AND LENGTH ON THE FRACTURE RESISTANCE OF ENDODONTICALLY TREATED TEETH ABSTRACT……………………………………………………………………... 47 INTRODUCTION………………………………………………………………. 48 METHODS AND MATERIALS………………………………………………... 50 RESULTS……………………………………………………………………….. 57 DISCUSSION…………………………………………………………………… 63 CONCLUSIONS………………………………………………………………... 69 REFERENCES………………………………………………………………….. 70 APPENDICES…………………………………………………………………… 75 iv LIST OF TABLES CHAPTER 1 Table 1. Mechanical data for Tested Posts (Reproduced from Torbjorner et. al., 1996) ……………………………………………………...... 23 Table 2. Experimental Setup of Posts Tested at Respective Lengths …………………... 43 Table 3. Pilot Study Load Values Using FibreKor Posts ……………………………….. 44 CHAPTER 2 Table 1. Experimental Design for Testing………………………………………………. 51 Table 2. Average Diameter and Flexural Modulus for Different Post Types………….... 57 Table 3. Group Differences of Least Squares Means Using 1-way ANOVA for Initial Failure Load After a Bonferroni Adjustment…………….……….... 59 Table 4. 2-way ANOVA for Initial Failure Load Based on Post Type and Post Length…………………………………………………………………….. 59 Table 5. Post Type and Length differences of Least Squares Means Using 2-way ANOVA for Initial Failure Load After a Bonferroni Adjustment……... 59 Table 6. Group Differences of Least Squares Means Using 1-way ANOVA for Ultimate Failure Load After a Bonferroni Adjustment…………….….…... 60 Table 7. 2-way ANOVA for Ultimate Failure Load Based on Post Type and Post Length…………………………………………………………………….. 60 Table 8. Post Type and Length differences of Least Squares Means Using 2-way ANOVA for Ultimate Failure Load After a Bonferroni Adjustment…... 61 Table 9. Mode of Ultimate Failure for Test Groups………………………….…………. 61 v LIST OF FIGURES CHAPTER 1 Figure 1. Effect of post length on core bond failure load (Pilot study)…………............... 45 Figure 2. Effect of post length on maximum failure load (Pilot study)………….............. 45 CHAPTER 2 Figure 1. Parapost XP, Light Post and Snowlight posts …………………………………. 50 Figure 2. Silicone simulated periodontal ligament space (in black)……………………... 53 Figure 3. Prefabricated Delrin sleeve and alignment post………...………………........ 53 Figure 4. Translucent VPS core former using post and prefabricated Delrin sleeve………...……………….............................................................. 53 Figure 5. Core and post space after prefabricated Delrin sleeve removed……….......... 53 Figure 6. Post cemented and core material injected into space to create core…………… 53 Figure 7. Core former removed and core finished to 4 mm height…………………......... 53 Figure 8. Schematic diagram of post-and-core samples…………..…………………........53 Figure 9. Sample mounted 1 mm from CEJ……………………….…………………....... 53 Figure 10. Typical loading curve for sample showing initial failure and ultimate failure……………………….………………….................................... 58 Figure 11. Average initial failure load based on post type and post length…………..........58 Figure 12. Average ultimate failure load based on post type and post length…………….. 60 Figure 13. Parapost XP 10 mm showing vertical core fracture…………….. …………….. 62 Figure 14. Average ultimate failure load based on post type and post length…………….. 62 Figure 15. Parapost XP 10 mm showing total core fracture………………...…………….. 62 vi Figure 16. Light Post 10 mm showing tooth-core debond, core fracture, and post bending……………………………………………………………………. 62 Figure 17. Parapost XP 5 mm showing tooth-core debond and subsequent root fracture… 62 Figure 18. Snowlight 5 mm showing tooth-core debond, post bending, and post pullout ... 62 Figure 19. Snowlight 5 mm showing post pullout and core-post debonding……………… 62 vii CHAPTER 1 INTRODUCTION Background and Significance The use of metallic posts in the restoration of endodontically treated teeth has been a mainstay in dentistry. However, metallic posts present with several clinically significant deficiencies. A dark shine through effect may be evident when using metallic posts and cores. In addition, metallic posts may cause discoloration of the surrounding tissues due to corrosion products. This is an esthetic concern, especially in the restoration of anterior teeth. Furthermore, metallic posts have a greater stiffness than the surrounding dentin, leading to increased stress concentration within root structure and possible root fracture during masticatory function. The advent of non-metallic posts has begun to address these concerns. Carbon and glass fiber-reinforced posts have been developed with stiffness values closer to that of human dentin. Esthetic posts made from glass or quartz fiber allow improved esthetics when all- ceramic crowns are to be placed. With the wide range of non-metallic posts being introduced and used in clinical dentistry, it is important to understand the properties of these materials and their limitations. In vitro mechanical testing of post-and-core treated teeth provides information as to failure characteristics given a particular loading scenario. Factors that play a role in fracture resistance of a post-and-core system include, but are not limited to, the amount of tooth remaining, the post design, post length, post stiffness, and the type of core material. In addition, several studies have examined the impact of a crown ferrule placement around a tooth for improving retention and fracture resistance. However, few studies have examined the clinical situation where a sufficient ferrule cannot be placed. In clinical cases where little or no coronal tooth structure remains and crown lengthening is not an option, use of a post-and-core restoration serves as the primary source of retention for a crown. Ideally a balance between the post length within root and the coronal extension should exist. With previous pre-fabricated post systems, authors have indicated varying theories on this balance. Some have advocated the use of the longest post possible as long as the apical seal is not disturbed. Others have advocated that the post be longer than the
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