The use of a fiber sleeve to improve fracture strength of pulpless teeth with flared root canals

Highlights

  • The FRP/sleeve combination effectively reinforced plupless premolars with flared root canals under firm bonding condition.

  • The maximal principle stress in restored premolars increased dramatically, once interfacial de-bonding extended to their cervical region.

  • Further firm bonding at the resin/dentin interface in an entire root should be achieved to reinforce pulpless premolars with flared root canals.

Abstract

Objectives

This study aimed to investigate how use of a fiber sleeve may reduce interfacial debonding and improve fracture strength of pulpless teeth with flared root canals.

Methods

Pulpless premolars with flared root canals were restored either with a fiber-reinforced post (FRP) alone or with an FRP wrapped in a hollow tubular fiber sleeve. A normal root restored with an FRP alone served as a control. The integrity of resin–dentin and resin–fiber interfaces in the restored roots was evaluated by a stereoscopic system after penetrating a dye. Four roots were tested for each experimental group. Fracture resistance in pulpless premolars with flared root canals restored with an FRP alone or with an FRP/sleeve combination were investigated under bonded and non-bonded conditions with static fracture testing ( n = 8), and stress distribution in these restored premolars were tested by finite element analysis (FEA).

Results

Flared root canals restored with an FRP/sleeve combination demonstrated superior integrity at the cervical resin–dentin interface to root canals with an FRP alone. Premolars with a flared root canal restored with an FRP/sleeve combination showed significantly greater fracture resistance compared with premolars restored with an FRP alone. FEA showed that once interfacial de-bonding extended to the cervical region of the root, stress concentration in the root dentin dramatically increased.

Significance

The FRP/sleeve combination was effective in reducing debonding and, hence, improving the fracture strength of pulpless premolars with flared root canals.

Introduction

Vertical root fracture of pulpless teeth, particularly those with flared root canals, remains a serious clinical problem , even though the use of fiber-reinforced posts (FRP) has improved the long-term clinical performance of restored teeth . Recently, various fiber materials have been developed in different shapes, including ribbon-like and tubular, maximally to fill the root canal and enhance the interfacial integrity between restoratives and tooth structures . Researchers have tried to develop the best method of reinforcing pulpless teeth with flared root canals . One of the effective methods may be the use of an “anatomical post”, where an FRP is relined by composite so that the shape of the post-core matches those of a retorting flared post space. This method is certainly effective to reduce the volume of luting material, which is beneficial to minimize its polymerization shrinkage. However, the elastic property of an “anatomical post” can not be similar to root dentin because of the high rigidity of the outer composites.

When restoring a flared root canal, maximizing the volume of fiber material in a post space can be efficient in improving its fracture strength, because it makes it possible to maintain the similar elasticity of restoring materials to the remaining dentin as well as reducing the volume of luting material. Based on this idea, in this study, our restoration method was to use an FRP wrapped in a hollow tubular sleeve to reinforce a pulpless tooth with a flared root.

Achieving an ideal tooth-restoration monoblock is an important step in reinforcing an endodontically treated root, provided reliable adhesion between restoratives and root dentin is achieved . The most common clinical failure in teeth restored with FRP is post dislodgement resulting from interfacial de-bonding . Finite element analysis (FEA) has shown that the risk of fracture increases when FRP de-bonds from the root, a finding that underscores the importance of interfacial bonding in reinforcing pulpless teeth . However, it is not easy to achieve excellent bonding in a small post space for various reasons . Comprehensive understanding of the behavior of root canal dentin in the post space may be the key to achieving better adhesion. Clinicians have to deal with the high shrinkage stresses in the post space because of its extremely high C-factor. When using light-cured and even dual-cured materials, it is essential to ensure deep and complete light penetration to obtain uniform bonding strength throughout the post space. Chemically cured adhesive materials should be considered for root canal bonding. In every case, careful attention must be paid to the negative effects of endodontic irrigation solutions, such as sodium hypochlorite and EDTA, on root canal adhesion.

The aim of this study was to investigate how a fiber sleeve can reduce interfacial debonding and improve fracture strength of pulpless teeth with flared root canals. The interfacial integrity between fiber materials and flared roots was evaluated. Fracture testing and FEA were also conducted to assess which fiber materials significantly strengthened pulpless premolars with flared root canals. The null hypothesis of this study was that the use of a fiber sleeve did not strengthen pulpless premolars with flared roots by reducing interfacial debonding.

Materials and methods

The materials used in this study are listed in Table 1 . A schematic of the experimental design, including the preparation of specimens, is presented in Fig. 1 .

Table 1
Resinous and fibrous materials used for post-core restorations.
Materials Principle components Lot Manufacturers
Hybrid Coat II MMA, 4-META, Aromatic amine, Aromatic sulfinate solution, Acetone, Water ES3 Sun Medical
Super Bond SEP Ethanol, Water soluble polymer EE1 Sun Medical
i-TFC fiber post (Ø = 1.1 mm) Glass fiber, Optical fiber VR1F Sun Medical
i-TFC fiber sleeve (Ø = 2.0 mm) Glass fiber VR3F Sun Medical
i-TFC post resin Barium silica glass, Bis-MPEPP, Aromatic diol based methacrylate acid ester ET2 Sun Medical
i-TFC core resin Barium silica glass, Bis-MPEPP, UDMA ES1 Sun Medical
Porcelain Liner M Liquid A: MMA, 4-META
Liquid B: MMA, Silicon analog
ER1 Sun Medical
Panavia F 2.0 Base: Hydrophobic aromatic and aliphatic dimethacrylate, sodium aromatic sulfinate, N,N-diethanol-p-toluidine, sodium fluoride, silanized barium glass
sodium benzene sulfinate Catalyst: MDP, hydrophobic aromatic and aliphatic dimethacrylate, photoinitiator, dibenzoyl peroxide, hydrophilic dimethacrylate, silanized silica ED Primer II: HEMA, MDP, 5-NMSA, dimethacrylate, sodium benzene sulfinate, water, accelerator
011248 Kuraray Noritake Dental
MMA, methyl methacrylate; 4-META, 4-methacryloxyethyl trimellitate anhydride; Bis-MPEPP, 2,2-bis[(4-methacryloxyethoxy)phenyl]propane; UDMA, urethane dimethacrylate; MDP, 10-methacryloyloxydecyl dihydrogen phosphate; HEMA, 2-hydroxyethyl methacrylate; 5-NMSA, N-methacryloyl 5-aminosalicylic acid.

Fig. 1
Schematic of experimental design, including preparation of specimens. (a) Selection of single-rooted premolars. (b) Removal of crown followed by endodontic treatments. (c) Experimental groups. FRP group: flared root restored with an FRP alone; FRP/sleeve group: flared root restored with combination of an FRP and a fiber sleeve; control group: normal root restored with an FRP; non-bonded FRP and FRP/sleeve groups: non-bonded equivalents of FRP and FRP/sleeve groups. The FRP and FRP/sleeve groups, and the control group were designed for interfacial integrity analysis; while the FRP and FRP/sleeve groups and the non-bonded FRP and FRP/sleeve groups were used for static fracture testing and FEA. (d) Interfacial integrity analysis: after sectioning six discs from each root, we observed the ratios of gap formation at resin–dentin and resin–fiber interfaces. (e) Static fracture testing: after restoration with a resin core and a metallic crown, all specimens were subjected to static fracture testing. (f) FEA was performed on the restored premolars under various bonding conditions.

Evaluation of interfacial integrity

Twelve extracted maxillary and mandibular human premolars were stored in a saline solution at 4 °C and used within 3 months of extraction. Single-rooted premolars free of caries and fractures were selected ( Fig. 1 a). Protocols were approved by the Ethics Committee of Osaka University. The crowns of teeth to be restored with post cores were removed with a low speed diamond saw (Isomet III, Buehler, Lake Bluff, IL, USA) at the cemento-enamel junction. Teeth were then endodontically instrumented with a size 40 file, and the root canals were obturated with gutta-percha and a resin-based endodontic sealer (AH-Plus, Dentsply, York, PA, USA) ( Fig. 1 b). The premolars were then divided into three groups, with four roots in each ( Fig. 1 c).

Flared root canals with at least 1 mm of dentin remaining in the walls were prepared by endodontic drills to two-thirds of the root depth in eight endodontically obturated roots. The thickness of the dentin walls was standardized at 1 mm by marking reference points on the top surface of the roots and preparation was performed by measuring wall thickness with digital calipers (Digimatic Calipers, Mitsutoyo, Tokyo, Japan). The thickness of the dentin walls was confirmed with bucco-palatal and mesio-distal radiographs . Ferrules with a height of 2.0 mm were also prepared.

The 12 premolars were divided into three groups of four specimens in each. Those in the FRP group were then reconstructed with a 1.1-mm optical FRP (i-TFC fiber post, Sun Medical, Shiga, Japan). Specimens in the FRP/sleeve group were reconstructed with an FRP wrapped in a hollow tubular fiber sleeve (i-TFC fiber sleeve, Sun Medical). The remaining four obturated roots served as a control group. In these roots, a 1.3-mm cylindrical post space with ferrules was prepared and restored with an FRP alone. After conditioning with 3% EDTA for 2 min followed by irrigation with saline solution, the post space in all teeth was coated with a self-etching adhesive agent (Hybrid Coat II, Sun Medical). Fiber materials pretreated with a silane coupling agent (Porcelain Liner M, Sun Medical) were then bonded with resin cement (i-TFC post resin, Sun Medical) and light-cured for 40 s. All specimens were stored at 37 °C with 100% humidity for 24 h. To prevent additional light penetration through the thinned dentin wall, all roots were wrapped with opaque adhesive tape.

The flared post space in each root was divided into three areas—cervical, middle, and apical—according to vertical location. Two 1.1-mm slabs were obtained from each area by slicing perpendicular to the tooth axis with a low-speed diamond saw ( Fig. 1 d). Six slabs were obtained from each prepared root, for a total of eight slabs from each vertical region from each group.

To evaluate the integrity of the resin–dentin and resin–fiber interfaces, a 1.0% acid red propylene glycol dye solution (Caries Detector, Kuraray Noritake Dental, Tokyo, Japan) was applied for 5 s, then rinsed and gently dried. A digital image of each slab was obtained with a stereoscopic system (NIS Elements D 3.00, Nikon, Melville, NY, USA) at a magnification of 40×. The ratio of the gaps at each interface was calculated using image analysis software and expressed as a percentage of the entire length of the interface.

The results were presented by means and standard errors, since averages of two values from the each third vertical location were used. Three-way analysis of variance (ANOVA) and Student–Newman–Keuls tests were used to analyze the effects of restoration type, vertical location in the root, and adhesion interface on the ratio of gaps at a significance level of α = 0.05.

Fracture testing

Thirty-two single-rooted maxillary and mandibular human premolars were selected ( Fig. 1 a), and their bucco-palatal and mesio-distal dimensions and root lengths were measured with digital calipers (Digimatic Calipers). The teeth were then divided into four groups ( n = 8 teeth each) so that there were no significant differences among groups in terms of bucco-palatal or mesio-distal dimensions, according to the Bartlett test and ANOVA at a 95% level of confidence.

Flared roots were prepared and restored using the same methods as those described for FRP and FRP/sleeve groups in the interfacial integrity evaluation ( Fig. 1 b and c). In addition, the non-bonded FRP and FRP/sleeve groups were prepared as the non-bonded equivalents of the FRP and FRP/sleeve groups, respectively. That is, the restoration procedures were the same, except that the adhesive agent was replaced by a resin separator (Super-Bond SEP, Sun Medical), leaving the fiber materials non-bonded to the root dentin.

All flared roots were restored with a core build-up (i-TFC core resin, Sun Medical) with a standardized shape produced with a plastic former. After restoration with a metallic full crown (Casting Gold Type II, Morita, Osaka, Japan) luted with resin cement (Panavia F 2.0, Kuraray Noritake Dental), the root surface was coated with approximately 200 μm of polyvinylsiloxane impression material (Duplicone, Shofu, Kyoto, Japan) to simulate the periodontal ligament. Finally, the restored specimen was embedded in an epoxy-acrylic resin block (Quetol 812, Nisshin EM Corporation, Tokyo, Japan) at a depth 2 mm below the cemento-enamel junction. All specimens were stored at 37 °C and 100% humidity for 24 h before fracture testing.

A 45° oblique load was applied to the center of the functional cusp of the restored teeth at a crosshead speed of 0.5 mm/min with a universal testing machine (Autograph AG-IS 20-KN, Shimadzu, Kyoto, Japan) until fracture ( Fig. 1 e) . Crack propagation areas were stained with caries detector dye and identified with a stereomicroscope at 40× magnification. Crack propagation was classified into one of three categories: cervical (fractures extending ≤1/3 the length of the root longitudinally from the cervical portion), middle (fractures extending between 1/3 and 2/3 from cervical toward apical portion), or apical (fractures extending longitudinally to the apical third of the root).

Fracture loads were recorded and compared among groups using two-way ANOVA and the Student–Newman–Keuls post hoc test. The distributions of crack propagation were compared with Fisher’s exact test. All statistical analyses were performed at a significance level of α = 0.05.

Finite element analysis ( Fig. 1 f)

ABAQUS 6.10 software (Rising Sun Mills, Providence, RI, USA) was used to perform FEA. A representative intact premolar was scanned with micro-computed tomography (XT H 225, Nikon Metrology, MI, USA), to obtain 1295 slices. Of these, 648 were selected for modeling and converted into a digital 3D finite element model. Thereafter, a digital representation of a flared root canal was created, in which the thickness of the remaining dentin wall in the coronal 2/3 of the root was constant at 1 mm, by enlarging the root canal.

The properties of materials used for the analyses were summarized in Table 2 . All materials were considered homogeneous, linear-elastic, and isotropic, with the exception of the orthotropic FRP. A finite element mesh was generated with linear isoparametric tetrahedral elements; 620,584 tetrahedron elements and 116,132 nodes were created. The nodes in the upper and lateral portions of the bone were fixed at 6 degrees of freedom.

Table 2
The material properties used in the FEA.
Materials Young’s modulus (GPa) Poisson ratio References
Marrow bone 1.4 0.3
Cortical bone 13.7 0.3
Periodontal ligament 1.18 × 10 −3 0.45
Dentin 18.6 0.31
Gutta-percha 0.14 0.49
Resin cement 8.3 0.28
Glass fiber post
Transverse 9.5 0.27
Longitudinal 37 0.34
Composite resin (core) 12 0.33
Gold alloy 120 0.33

A set of digital models ( Fig. 2 a; Model 0 represents the original mode) was established for each of the four experimental groups used in the fracture testing. In the FRP and FRP/sleeve groups, fiber materials were programmed to be perfectly bonded to dentin, while in the non-bonded FRP and FRP/sleeve groups, the resin–dentin interfaces were defined as completely non-bonded (i.e., the cement could slide along or separate from the dentin wall). The friction coefficient was 0.3 .

Fig. 2
Finite element analysis of the premolars with flared root canals restored with fiber materials under bonded and non-bonded conditions. (a) A series of models was established for each group to simulate the progress of interfacial failure during static loading. The white interfacial lines indicated by arrows represent the interfacial detachment modes identified. (b) Stress distribution in the original mode (Model 0) in each group. (c) The maximum principle stress developed in the components including dentin, resin cement and fiber materials of the restored teeth during progressive interfacial failure.

To simulate the initiation and propagation of interfacial failure during the fracture test loading, a series of models was developed for each group according to the extent of interfacial failure along the resin–dentin interface ( Fig. 2 a, Models 1–5). A 100 N static load was applied at the center of the lingual cusp at a 45° angle to the long axis of the tooth. The stress distributions and magnitudes were recorded for each model.

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Nov 23, 2017 | Posted by in Dental Materials | Comments Off on The use of a fiber sleeve to improve fracture strength of pulpless teeth with flared root canals
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