Adhesion Poste Ferrari

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Evaluation of the adhesion of fiber

posts cemented using differentadhesive approaches

Ivana Radovic1,2, Claudia Mazzitelli2,Nicoletta Chieffi2, Marco Ferrari2

1Clinic for Paediatric and Preventive Dentistry,Faculty of Dentistry, University of Belgrade,Belgrade, Serbia; 2Department of DentalMaterials and Restorative Dentistry, Universityof Siena, Policlinico Le Scotte, Viale Bracci,Siena, Italy

Reconstructing endodontically treated teeth with fiberpost-and-core systems has been widely investigated (1,2). This treatment option may offer advantages overconventional cast posts or prefabricated metallic posts(39). Notwithstanding the satisfactory clinical perfor-mance of fiber post-and-core systems (10), debonding ofthe post was observed as the main failure mode (1115).

The success of fiber post-and-core restorative proce-dures depends, in part, on the cementation techniqueused to create a link between the post and root canal

dentin. Contemporary resin cements may be divided intothree subgroups according to the adhesive approach used

to prepare the tooth prior to cementation. The firstgroup utilizes etch-and-rinse adhesive systems. In the

second group, enamel and dentin are prepared using self-etching primers. The third, and most recently introducedgroup of resin cements, is represented by self-adhesivecements.

In themajorityof clinical investigations,fiber posts werecemented using etch-and-rinse adhesives in combinationwith self-cured (13, 1518) and dual-cured (1214, 1922)resin cements. It was reported that the level of experienceof the operator does not influence the retention of fiberposts cemented using etch-and-rinse adhesive underlaboratory conditions (23). Nevertheless, scientists andmanufacturers have been continuously challenged by a

general trend to simplify the clinical procedures. The

simpler, self-etching adhesive approach offers a shorteradhesive application time anda reduced numberof clinicalsteps. It is considered to be less technique-sensitive becausethe clinical assessment of optimal dentin wetness after

rinsing the phosphoric acid is avoided (24). However, themost simple, one-step self-etching adhesives are alsoassociated with permeability and phase separation that

may affect bond durability (25).The adhesion of fiber posts luted using self-etching

adhesives has been assessed only in laboratory studies,

most commonly by comparing them with the perfor-mance of etch-and-rinse adhesives. The findings on the

performance of self-etching adhesives in fiber postcementation are not consistent. It was reported that

microleakage at the cementroot dentin interface wassignificantly higher when self-etching primer was used forfiber post cementation, in comparison with etch-and-rinse adhesive (26). Likewise, the resinroot dentininterdiffusion zone was less pronounced with the self-etching approach than with the etch-and-rinse adhesiveapproach (27). However, no differences between self-etching and etch-and-rinse approaches were found whenrepresentative materials were investigated using themicrotensile bond strength test (28) and the push-outstrength test (29, 30).

Self-adhesive cements represent the least investigated

group of resin cements. Their in vitro performance in

Radovic I, Mazzitelli C, Chieffi N, Ferrari M. Evaluation of the adhesion of fiber posts

cemented using different adhesive approaches. Eur J Oral Sci 2008; 116: 557563.

2008 The Authors. Journal compilation 2008 Eur J Oral Sci

The aim of this study was to investigate the adhesion of fiber posts cemented with

luting agents that utilize three currently available adhesive approaches: etch-and-rinse,

self-etch, and self-adhesive. Forty-two intact single-rooted human premolars were

used in the study. Teeth were divided into six groups. In each group, a different resin

cement with its adhesive system (if needed) and a fiber post were used. The groups

were classified, according to the adhesive approach, into the following three categories.(i) Etch-and-rinse groups: Calibra resin cement/XPBond adhesive + self-curing acti-

vator (SCA)/RadiX Fiber Post (Dentsply Caulk), FluoroCore 2 core build-up mate-

rial/XPBond + SCA/RadiX Fiber Post (Dentsply Caulk), and MultiCore Flow luting

and core build-up material/Excite DSC adhesive/FRC Postec Plus fiber post (Ivoclar

Vivadent). (ii) Self-etch group: Panavia F 2.0/ED primer (Kuraray)/RadiX Fiber Post

(Dentsply Caulk). (iii) Self-adhesive groups: experimental self-adhesive cement/RadiX

Fiber Post (Dentsply Caulk), and RelyX Unicem/RelyX Fiber Post (3M ESPE). The

adhesion between the post and the root canal walls was assessed using the thin-slicepush-out test. In the test arrangement used, the self-etching approach may offer less

favourable adhesion to root canal dentin in comparison with etch-and-rinse and self-

adhesive approaches.

Dr Ivana Radovic, Clinic for Paediatric andPreventive Dentistry, Faculty of Dentistry,University of Belgrade, Dr Subotica 11, 11000Belgrade, Serbia

Telefax: +381112685361E-mail: [email protected]

Key words: dentin-bonding agents; post-and-core technique; resin cements

Accepted for publication September 2008

Eur J Oral Sci 2008; 116: 557563Printed in Singapore. All rights reserved

2008 The Authors.Journal compilation 2008 Eur J Oral Sci

European Journal of Oral Sciences


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fiber post cementation was investigated using the push-out strength test (3135), and the results are contradic-tory. In comparison with the etch-and-rinse approach,both lower (31, 32, 35) and higher (34) push-outstrengths of self-adhesive cement were reported. Com-pared with the self-etching approach, inferior (32),comparable (31), and superior (33) behaviour of the self-adhesive approach was reported, even though the sameself-adhesive cement was investigated in all the studies.In the only clinical study available, no failures were

recorded after 2 yr of follow-up of restorations retainedby fiber posts cemented with self-adhesive cement (36).

Self-etching and self-adhesive approaches offer sim-

plicity and chair-time reduction, which may be beneficialin the clinical setting. However, information on whichfiber post cementation technique might be most favour-able is currently lacking in the literature. Therefore, the

aim of this study was to investigate the adhesion of fiberposts cemented to intraradicular dentin with luting agents

that utilize three currently available adhesive approaches:etch-and-rinse, self-etch, and self-adhesive. The workinghypothesis was that the simpler, self-etching, and self-adhesive approaches are equally as effective as the clini-cally proven etch-and-rinse approach. The null hypothesistested is that there are no differences in the retention offiber posts cemented with different luting agents.

Material and methods

Specimen preparation

Forty-two intact human premolars with a single root canal,

extracted for orthodontic reasons, were selected for use inthe study. The teeth were hand-scaled and stored in 1%chloramine T at 4C for no more than 6 months until use.The crown of each tooth was removed 1 mm above thecementoenamel junction, using a slow-speed diamond saw(Isomet; Buehler, Lake Bluff, IL, USA) under copiouswater-cooling. The roots were endodontically instrumentedat a working length of 1 mm from the apex using a #35master apical file (Maillefer, Ballaigues, Switzerland),Gates-Glidden drills #2 to #4 (Maillefer), and 2.5% sodiumhypochlorite irrigation. For canal obturation, thermoplas-ticized, injectable gutta-percha (Obtura; Texceed Corp.,Costa Mesa, CA, USA) and a resin sealer (AH Plus Jet;Dentsply DeTrey, Konstanz, Germany) were employed.Teeth were randomly divided into six groups. In each group,

a different resin cement with its adhesive system (if needed)and a fiber post were used. The groups were classified,according to the adhesive approach, into three categories:etch-and rinse, self-etch, and self-adhesive. In each root-treated tooth, a 9-mm-deep post space was prepared usinglow-speed drills provided by the post manufacturer. Thematerials were handled in strict accordance with themanufacturers instructions.

Etch-and-rinse groups(i) Calibra resin cement, XPBond adhesive/self-curingactivator (SCA), RadiX Fiber Post (Dentsply Caulk, Mil-ford, DE, USA).

The RadiX Fiber Post was cleaned with alcohol, air-dried, and treated with Calibra Silane. Caulk 34% Tooth

Conditioner Gel was applied to the post space through a

needle and rinsed off after 15 s with water using an end-odontic syringe. Excess water was removed with a gentleair blast. Paper points were used to remove residualmoisture without desiccating the etched dentin surface.XPBond adhesive was mixed with SCA (1:1), applied tothe post space with a microbrush for 20 s, gently air dried,

and then excess was removed using paper points. Calibracement components were mixed 1:1, and then mixed cementwas spread on the surface of the post and in the postpreparation using a lentulo spiral. The post was seatedimmediately and light-curing was performed through thepost for 40 seconds using a conventional quartztungstenhalogen light (600 mW cm)2 output; VIP; Bisco, Schaum-burg, IL, USA).

(ii) FluoroCore 2 core build-up material, XPBond adhe-sive/SCA, RadiX Fiber Post (Dentsply Caulk).

The RadiX Fiber Post was cleaned with alcohol and airdried. Caulk 34% Tooth Conditioner Gel and XPBondadhesive with SCA were applied as in group (i). FluoroCore2 base and catalyst were mixed at a ratio of 1:1 for 30 s. Themixture was applied on the post and the post was seated

immediately. The material was allowed to autocure for7 min. Light curing was performed through the post as ingroup (i).

(iii) MultiCore Flow luting/core build-up material, ExciteDSC adhesive, and the FRC Postec Plus fiber post (IvoclarVivadent, Schaan, Liechtenstein).

The FRC Postec Plus post was cleaned with phosphoricacid gel (Total Etch) for 60 s, rinsed, and dried. MonobondS was applied on the post and dried after 60 s. Total Etchwas applied to the post space through a needle and rinsedoff after 15 s with water using an endodontic syringe. Excesswater was removed as in group (i). Excite DSC adhesivewas activated, applied to the post space with a proprietarymicrobrush for 10 s, and then gently air dried. Excessadhesive was removed using paper points. MultiCore Flow

components were mixed and applied to the post. The postwas seated immediately and light curing was performedthrough the post as in group (i).

Self-etch group(i) Panavia F 2.0, ED primer (Kuraray, Osaka, Japan) andRadiX Fiber Post (Dentsply Caulk).

The RadiX Fiber Post was cleaned with alcohol and airdried. The ED primer II was mixed at a ratio of 1:1, appliedto the post space with a microbrush for 30 s, gently airdried, and then excess was removed using paper points.Panavia F 2.0 paste A and paste B were mixed for 20 s andapplied to the post. The post was seated immediately andlight curing was performed through the post as in group (i)of the etch-and-rinse groups.

Self-adhesive groups(i) Experimental self-adhesive cement and the RadiX FiberPost (Dentsply Caulk).

The RadiX Fiber Post was cleaned with alcohol and airdried. Experimental cement was applied directly to the postspace through an endodontic application tip that is attachedto the double syringe. The post was seated immediately andthe cement was allowed to autocure for 5 min. Light curingwas then performed through the post as in group (i) of theetch-and-rinse groups.

(ii) RelyX Unicem and RelyX Fiber Post (3M ESPE, See-feld, Germany).

The RelyX Fiber Post was cleaned with alcohol and airdried. After mixing the capsule, RelyX Unicem cement was

applied directly to the post space through a disposable

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application tip that is attached to the capsule. The post wasseated immediately and the cement was allowed to autocurefor 5 min. Light curing was then performed through thepost as in group (i) of the etch-and-rinse groups.

The composition and batch numbers of all materials usedin this study are reported in Table 1. Following placement

of the fiber post, in each group, excess luting agent wasremoved prior to light curing. The exposed dentin alongthe coronary part of the root and the coronal part of theluting agent/fiber post were completely covered with glassionomer cement (Fuji II; GC Corp., Tokyo, Japan). Afterstorage in water for 24 h at 37C (ISO Standard DentalmaterialsTesting of adhesion to tooth structure; ISO/TS11405:2003), the roots were processed for evaluation of thepush-out strength.

Push-out strength evaluation

In order to assess the adhesion of fiber posts, the thin-slicepush-out test was used (37). The portion of each root that

contained the bonded fiber post was sectioned into five orsix 1-mm-thick serial slices using the Isomet saw (Buehler)under water cooling (Fig. 1). Seven bonded roots from eachgroup resulted in 3542 slices per group for push-outstrength evaluation. None of the slices failed during sec-tioning, and all fabricated slices were used for the evaluationof push-out strength. The number of slices in each experi-mental group of at least 35 was determined from a pre-liminary power analysis that was conducted in order toassure power of at least 90% for finding the statisticallysignificant differences given the standard value of type Ierrors (0.05) and assuming the difference of 4 MPa as rele-vant for this investigation. The within-group standarddeviation that was used in the calculations was assumed tobe 4 MPa, based on the previous investigations of push-outstrength (38). The sample size and power calculations werehandled by sigmastat (Systat Software, San Jose, CA,USA). The thickness of each slice was individually measuredusing a digital calliper and then each slice was firmlyfixed with cyanoacrylate glue to a loading fixture. Acompressive load was applied on the apical aspect of the slicevia a universal testing machine (Triax Controls, Milano,Italy) that was equipped with a 1-mm-diameter cylindricalplunger.

The plunger was positioned so that it only contacted thebonded post on loading, introducing shear stresses along thebonded interfaces. The loading force was extended in anapical-coronal direction, in order to move the post towardsthe larger part of the root slice. Loading was performed at aspeed of 0.5 mm min)1 until failure, as manifested by theextrusion of the post segment from the root slice. This wasfurther confirmed by the appearance of a sharp drop alongthe load/time curve recorded by the testing machine. Thepush-out strength (MPa) was computed by dividing theload at debonding (N) by the area (A) of the bondedinterface. The latter was calculated through the formula:A pR rh2 R r20:5 where R represents thecoronal post radius, r represents the apical post radius and his the thickness of the slice in mm. The diameters of the postand the thickness of the slice were individually measuredusing a digital calliper with 0.01-mm accuracy. The failuremode of each debonded specimen after the push-out testwas assessed using a stereomicroscope (Nikon SMZ645,Tokyo, Japan) at 40 magnification and classified accordingto the following criteria.

(i) Adhesive failure between dentin and the luting agent.(ii) Adhesive failure between the luting agent and the post.(iii) Cohesive failure within the luting agent.(iv) Cohesive failure within the post.(v) Mixed failure.

One slice representative of each failure mode was processedfor scanning electron microscopy (SEM) evaluation in orderto obtain SEM images of the failure patterns. The sliceswere rinsed in 96% alcohol solution for 1 min and air dried.Each slice was mounted on a metallic stub, sputter-coatedwith gold (Polaron Range SC7620; Quorum Technology,Newhaven, UK), and observed under a scanning electronmicroscope (JSM 6060 LV; JEOL, Tokyo, Japan).

Statistical analysis

To start with, regression analysis was conducted in eachgroup to check if the root of origin was a significant factorresponsible for differences in the push-out strengths of rootslices. The regression analysis revealed that in none of the

groups was the root of origin significant. Therefore, theslices were considered as independent statistical units withineach group. The normal distribution of the push-outstrength data was first checked and verified using the Kol-mogorovSmirnov test. A one-way analysis of variance(anova) was subsequently performed to assess the signifi-cance of the differences in push-out strength between theluting agents. As variances were homogeneous (Levenestest), one-way anova was followed by the Tukey test forpost hoc comparisons. The level of significance was set atthe 0.05 probability level in all analyses, and calculationswere handled using the spss 15.0 software (SPSS, Chicago,IL, USA).

Results

The type of luting agent significantly influenced themeasured push-out strengths (P < 0.001). The results ofpush-out strength testing are summarized in Table 2.Multiple comparisons revealed that the push-outstrengths of Calibra (etch-and-rinse approach) andRelyX Unicem (self-adhesive approach) were compara-ble and significantly higher than the push-out strengthsof FluoroCore 2 (etch-and-rinse approach) and PanaviaF 2.0 (self-etch approach). The push-out strengths ingroups where posts were cemented with MultiCore Flow(etch-and-rinse approach) and Experimental self-adhe-

sive cements were comparable with the push-outstrengths in all the other groups (Table 3). The distri-bution of failure modes is reported in Table 2. In themajority of groups the most frequent type of failure wasadhesive between dentin and cement (Fig. 2A), followedby adhesive failures between post and cement, and mixedfailures (Fig. 2B). No cohesive failures within the post

were observed in this study.

Discussion

The thin-slice push-out strength test is considered to be avalid method for evaluating fiber post adhesion to root

Adhesion of fiber posts 559


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canal walls (39). It has been shown to be more reliablethan the microtensile technique for measuring theadhesion of fiber posts (37). The thin-slice push-

out strength test is not difficult to use, and it allowsfabrication of several specimens out of one root, as wellas testing for regional differences between root sections(39). However, the manner in which the fiber post in a1-mm-thick root slice is exposed to dislodging forcesduring push-out testing cannot be directly comparedwith functional forces that the post needs to withstandduring clinical service. It is also possible that the sec-tioning process may induce artefacts that could influencetest results. This may partly serve as an explanation for

the relatively high coefficient of variation that was ob-served in some groups.

In each group, resin cement/adhesive was used with

the manufacturer recommended fiber post. The onlyexception was made in the case of Panavia F 2.0, as nospecific fiber post is recommended by the manufacturer(Kuraray). This experimental set-up has limitations,

as it was previously reported that push-out strengthmay be influenced by a type of fiber post to a greater

extent than by a luting agent (30). Nevertheless, it wasassumed that combining all the fiber post systemcomponents (resin cement, adhesive, and fiber post)from the same manufacturer would prevent possibleincompatibility between the materials and allowassessment of the full potential of each system underlaboratory conditions.

Significant differences were found between experi-mental groups, which led to the rejection of the nullhypothesis. Both self-adhesive groups were comparablewith Calibra and MultiCore Flow etch-and-rinsegroups. This finding is in contrast with some previous

Table 2

Push-out strengths and the percentage of slices that failed in the respective failure mode for each luting agent

Adhesive approach Luting agent

Push-out strength Failure modes (%)

Mean (SD) Med. 25% 75% AD AP CC M

Etch-and-rinse Calibra 12.70 (4.33) A 13.64 10.12 16.39 50 38 0 12

FluoroCore 2 8.07 (4.76) B 7.93 4.70 12.17 49 30 0 21

MultiCore Flow 11.14 (3.88) AB 12.62 8.39 13.88 32 50 0 18

Self-etch Panavia F 2.0 8.68 (5.29) B 8.41 3.67 12.42 47 20 18 15

Self-adhesive Experimental 10.61 (5.01) AB 9.69 5.40 15.38 56 25 0 19

RelyX Unicem 12.52 (5.47) A 11.33 8.88 15.63 62 5 0 33

Different letters indicate statistically significant differences (one-way analysis of variance and Tukey test, P < 0.05).SD, standard deviation; Med., median value; 25%, lower quartile; 75%, upper quartile; AD, adhesive failure between dentin and theluting agent; AP, adhesive failure between the luting agent and the post; CC, cohesive failure within the luting agent; M, mixed

failure.

Table 3

The resultant P-values of post-hoc comparisons between the groups (one-way analysis of variance and Tukey test)

Calibra FluoroCore 2 MultiCore Flow Panavia F 2.0 Experimental RelyX Unicem

Calibra 0.001 0.745 0.009 0.491 1.000

FluoroCore 2 0.001 0.050 0.994 0.213 0.001

MultiCore Flow 0.745 0.050 0.254 0.997 0.820

Panavia F 2.0 0.009 0.994 0.254 0.578 0.012

Experimental 0.491 0.213 0.997 0.578 0.574

RelyX Unicem 1.000 0.001 0.820 0.012 0.574

Significant P-values are in italics (P < 0.05).

Fig. 1. Schematic drawing of the specimen preparation forpush-out strength testing. Each root was sectioned into 1-mm-thick slices. The apical surface of each root slice was marked(M) in order to ensure that the loading force would be appliedin the apical-coronal direction, in order to move the post to-wards the larger part of the slice. C, luting agent; D, rootdentin; P, fiber post.



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investigations (31, 32, 35). The favourable push-outstrength of RelyX Unicem may be partly explained bythe fact that in the present investigation it was used withthe RelyX Fiber Post. According to the manufacturer s

claims, this postcement system offers both chemicalcompatibility and strong micromechanical postcementinterlocking. In previous investigations, RelyX Unicemwas used with the FRC Postec post (31, 32), the AesthetiPlus post (RTD, St Egreve, France) (35), and the C-Post(RTD) (35), which may account for the discrepancy inthe results. In the study by de Durao Mauricio et al. (32),the vast majority of testing failures was found betweenpost and cement, and no failures were observed betweendentin and cement, which may imply unsatisfactoryRelyX Unicem/FRC Postec coupling. On the contrary,in the present study the majority of failures were locatedbetween dentin and cement (Table 3). Furthermore,

after the initial 5-min period of self-curing, RelyXUnicem was light-cured in the present study, whereas inthe previous investigations it was used only in the self-

cure mode (32, 35). It was reported that light curingsignificantly increased the bond strength of RelyXUnicem to various types of ceramics (40, 41). Taking into

account the low degree of conversion of this cementwhen it is self-cured (42), it might be advisable to use it indual-cure mode.

Retention of quartz fiber posts cemented with the dual-

cure resin cement RelyX ARC in combination with anetch-and-rinse adhesive was comparable with the reten-tion obtained using RelyX Unicem (43) and these findingsare in accordance with the present investigation. The

push-out strength of Panavia F was significantly lower

than that of RelyX Unicem, and this result is consistentwith previous reports (33, 34). It is interesting to note thatcohesive failures within the luting agent were only seen inthe Panavia F 2.0 group. This may be the result of theunfavourable cohesive strength of this cement.

MultiCore Flow is formulated to be used both as thecement and as core material. Its push-out strength in the

present investigation was comparable with that of Cali-bra. Bearing in mind the favourable adhesion of thismaterial to silanized FRC Postec post (44), its clinical

use could offer advantages. Besides the procedure beingeasier and faster, it also results in fewer interfacesbetween different types of materials and therefore in less

potentially critical areas where failure could occur.Although FluoroCore 2 is a core build-up material, itwas included in this investigation following the sugges-tion of the manufacturer, in order to explore its potentialuse in luting fiber posts. However, its push-out strengthwas significantly lower in comparison with Calibra

(Table 3), even though both materials were used with thesame adhesive (XPBond). It may be speculated that theapplication mode and higher viscosity of FluoroCore 2in comparison with Calibra precluded its close adapta-tion to root canal walls, as FluoroCore 2 was applied tothe post only, whereas Calibra was first introduced intothe post space on a lentulo spiral.

This study assessed the push-out strengths of fiberposts after 24 h of water storage. It is possible that alonger storage time and/or thermal cycling would givedifferent results. Within the limitations of the presentinvestigation, it may be concluded that the 24-h push-outstrength of fiber posts was significantly influenced byluting agents. The study findings do not indicate with

certainty that any one of the three investigated adhesiveapproaches is better than the others. Nevertheless, in thetest arrangement used, the self-etching approach may

offer less favourable adhesion to root canal dentinin comparison with etch-and-rinse or self-adhesiveapproaches.

Acknowledgements The authors thank Dentsply Caulk for thegenerous donation of the materials used in the study. Specialthanks go to Architect Milan Stefanovic for graphic support.

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