Influence of Timing of Coronal Preparation on Retention of Cemented Cast Posts and Cores

Khalil Al-Ali, BDS, MSca Yousef Talic, BDS, MSb Tariq Abduljabbar, BDS, MS, PhDc Ridwaan Omar, BSc, BDS, LDS, MSc, FRACDS, FDSRCSEdd

Purpose: This study investigated the effect of coronal preparation by high-speed handpiece on the retention of cemented cast posts and cores. Materials and Methods: Cast posts and cores were fabricated for 90 extracted single-rooted human teeth cemented with zincphosphate cement and randomly divided into six groups of 15 specimens each. The six groups were matched randomly two by two, such that one of each of the matched groups was subjected to a 4-minute period of high-speed preparation of the cores. Castings from the first pair (1 and 2) were subjected to an axially directed removal force using a universal testing machine 15 minutes from the start of cement mixing; castings from the second (3 and 4) and third (5 and 6) pairs were tested at 1 hour and 24 hours, respectively, having been stored in water at 37C for the waiting periods. The forces required for dislodgment of posts from their prepared spaces were recorded. Data were statistically analyzed using two- and one-way ANOVA and the Students t test. Results: The results showed increased mean retentive strengths of posts as the time to testing increased for both unprepared and prepared groups. Significantly higher mean retentive strengths of posts were recorded for unprepared compared to prepared groups tested at 15 minutes and 1 hour after cementation. Conclusion: High-speed preparation had a significant negative effect on the retentive strengths of posts tested at 15 minutes and 1 hour after cementation, but not on those tested at 24 hours. Int J Prosthodont 2003;16:xxxxxx.

ignificant improvements in the predictability and prognosis of endodontic therapy have been achieved over the last two to three decades, in turn leading to an increased need for the restoration of such teeth.1,2 Furthermore, it is likely that the need to restore endodontically treated teeth will increase as more teeth are retained into older age.3 Posts serve the central purpose of retaining a core when much of the clinical crown has been destroyed. It follows that post-and-core retention and stability are crucial for the success of the final restoration.47 Post

aLecturer, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia. bAssociate Professor, Department of Prosthetic Dental Sciences, and Director of Postgraduate Dental Education, College of Dentistry, King Saud University, Riyadh, Saudi Arabia. cAssistant Professor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia. dProfessor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia.

Reprint requests: Dr Ridwaan Omar, King Saud University, PO Box 60169, Riyadh 11545, Saudi Arabia. Fax: + (9661) 2782287.

length, diameter, geometric design, surface configuration, and cement type are some of the mechanical factors that affect the retention and stability of posts.1,2,8,9 The nature and timing of forces acting upon teeth restored with posts and cores are also important. Such forces are predominantly functional (and sometimes parafunctional) in nature, and they may lead to instability of the cemented post-and-core system. Studies investigating the capacity of ultrasonic scalers to remove cemented posts from teeth have shown a positive correlation between the vibration so generated and loosening of posts.1012 Rotary instrumentation similarly produces vibration, which is a function of the characteristics of the handpiece mechanism, the diamond instrument, and the speed of rotation.13,14 It has been suggested that the vibration generated by rotary diamond instruments in a high-speed handpiece during preparation may adversely affect the cement film between the post and tooth, and so affect post retention.1517 A study investigating such an effect found no difference in retention between posts whose cores

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Table 1 Means and Standard Deviations of Forces (N) Required to Dislodge Posts in Each Group (n = 15)
Group 1 2 3 4 5 6 Experimental manipulation 15 min, without preparation 15 min, with preparation 1 h, without preparation 1 h, with preparation 24 h, without preparation 24 h, with preparation Mean 384 220 451 333 458 404 Standard deviation 155 107 88 90 111 138

had been prepared 1 hour after cementation and those that had been left unprepared, but also observed that post retention is reduced with increased severity of preparation.18 It would be more realistic clinically if a core were prepared sooner after the post-and-core cementation than the timeframe that was investigated in the cited study.18 The present purpose was to study the effect of high-speed handpiece core preparation on the retention of cemented cast posts and cores at different intervals after cementation. The hypothesis was that the earlier the preparation is carried out, the more detrimental is its effect on post retention.

Materials and Methods

Ninety freshly extracted, single-rooted intact teeth were cleaned of calculus by hand scaling, polished with pumice-water slurry, and stored in saline at room temperature. The coronal portion of each tooth was sectioned perpendicular to its long axis, approximately 2 mm above the facial cementoenamel junction (CEJ), leaving a flat coronal tooth surface. Root canal therapy was performed conventionally by hand instrumentation with K files up to No. 45 (Dentsply/Caulk), followed by Peeso reamers (Pulpdent) Nos. 1 through 5, at low speed, to a depth of 10 mm. Canals were not obturated. Post spaces were prepared using a No. 6 parallel-sided twist drill (Parapost Black P-42, Whaledent), to 1.5 mm in diameter and 10 mm in depth. Radiographs of all roots were taken mesiodistally and buccolingually to ensure that more than 1 mm of root dentin thickness remained after preparation.1 Water irrigation was used throughout all instrumentation. To complete the preparation, a No. 4 round carbide bur was used to produce a small depression on the root face to assist in subsequent orientation of the post and core. Serrated, cylindric, vented, plastic burnout post patterns (Parapost Black P-50-6, Whaledent) were passively placed in the prepared canals to the depth of

the prepared post space and cut to leave about 2 mm projecting above the canal orifice. Core blanks were modeled on a typical metal-ceramic tooth preparation. An extracted maxillary premolar was prepared using a flat-ended tapered diamond instrument in a high-speed handpiece, producing a 1.5-mm-wide circumferential shoulder placed 2 mm coronal to the facial CEJ. Ninety custom molds of the prepared tooth were made with medium-body polyvinyl siloxane impression material (Express, 3M Dental), from which 90 core pattern blanks were produced in inlay resin (Duralay, Reliance Dental). A core blank was centrally positioned on each of the test teeth, aligned as closely as possible to the long axis, with a hollowed inferior surface accommodating (but not contacting) the projecting plastic post. The core blank was connected to the post in its predetermined position on the root face by means of Duralay resin. The lug formed in the depression on the root face was subsequently aligned with the depression during cementation. Post-andcore patterns were sprued, invested, and cast in basemetal alloy (Bellabond, Bego). After separation of sprues, all castings were examined under 10 magnification for any casting defects. Each casting was taken to its respective tooth to verify its fit and adjusted if needed. Finally, the posts and cores were air abraded with 50-m aluminum oxide particles. All roots were grooved, and a length of 0.7-mm-diameter hard steel wire was looped through a transverse hole drilled near the apex of each root. Specimens were mounted with self-curing resin (Ortho Resin, Dentsply/DeTrey) in a short length of PVC pipe, using a dental surveyor (JM Ney) to orient the post space to the vertical axis. All posts and cores were cemented with zinc-phosphate cement (Cement Type I, Confi-Dental) mixed according to the manufacturers instructions. A No. 40 lentulo spiral filler (Paste Filler, Kerr/Sybron) was used to introduce the cement into the canal space. The post was coated with cement and slowly seated with finger pressure maintained for 8 minutes,19 after which excess cement was removed. The 90 specimens were randomly assigned to six groups of 15 each (Table 1). Three of the groups (2, 4, and 6) were subjected to preparation of their cores at different intervals (15 minutes, 1 hour, and 24 hours) after cementation using a coarse, tapered diamond instrument (No. 6836.314.014, Komet) in a high-speed handpiece with copious water irrigation. A new diamond instrument was used for each specimen, and one operator performed all preparations so that the technique could be regarded as reasonably consistent. Each core was prepared axially for 3 minutes and occlusally for 1 minute. These groups (2, 4, and 6) served as experimental groups, while the other three groups

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(1, 3, and 5) were not prepared and served as controls. Groups 1 and 2 (one unprepared, the other prepared) were tested for retention 15 minutes after the start of cement mixing. Similarly, groups 3 and 4 were tested 1 hour after cementation, and groups 5 and 6 were tested 24 hours after cementation. All specimens, except the 15-minute groups, were stored in a container of water and placed in a laboratory oven (Imperial IV, Lab Line Instruments) at 37C until testing. A customized, self-aligning apparatus was used for retentive testing. It consisted of a U-shaped stainless steel bar with small loops at each end to accommodate a passively fitting horizontal rod. When assembled, the horizontal rod passed through a channel prepared through the lower part of the PVC mounting ring as well as the loops of the U-shaped bar. A hook from the lower jaw of a universal testing machine (model 8500 PLUS Dynamic Testing System, Instron) engaged the bend of the U-shaped bar, while the upper jaw clamped the core to about 2/3 of its height A separating load was applied at a rate of 5 mm/min. Each sample was tested to failure, and the forces required for dislodgment of the posts were recorded. Two-way analysis of variance (ANOVA) with the interaction term was performed to compare mean forces for the preparation and time factors. This was followed by one-way ANOVA to test for significant differences in the means between the prepared (experimental) and unprepared (control) groups. When a significant difference was found, Tukeys comparison test was used to determine which group(s) differed. The Students t test was carried out to compare the unprepared and prepared groups at each time point. A result was considered statistically significant if P < .05. All analyses were carried out with SPSS Software, version 9 (SPSS).

not reach the 5% level of significance applied. Therefore, further analyses were performed using one-way ANOVA and the Students t test. To gain greater understanding of the differences in retention that may exist among the groups subjected to time variation only (unprepared groups 1, 3, and 5) and those subjected to both time variation as well as preparation (prepared groups 2, 4, and 6), further statistical analyses were performed using one-way ANOVA and Tukeys comparison test. Although there were no significant differences between the means of any of the unprepared groups, there were significant differences between the means of the groups prepared at 15 minutes (group 2) and 1 hour (group 4; P < .05), and between those prepared at 15 minutes (group 2) and 24 hours (group 4; P < .0001). Since one-way ANOVA showed different results for prepared and unprepared groups, the earlier assumption about the interaction effect seemed justified. When comparing time-matched unprepared and prepared groups, the Students t test showed significant differences in retention between groups 1 and 2 at 15 minutes (P < .01), as well as between groups 3 and 4 at 1 hour (P < .001). The difference in retention between the groups tested at 24 hours (groups 5 and 6) was not significant.

Discussion
The principal finding of this study was that the retention of posts and cores subjected to high-speed preparation of the core was significantly lower than that of unprepared equivalents when preparation was carried out 15 minutes and 1 hour after cementation. Similarly, the retention of posts and cores prepared 15 minutes after cementation was significantly lower than that of those prepared 1 and 24 hours after cementation. Although the setting time of zinc-phosphate cement has been specified at between 2.5 and 8 minutes,19 various investigators have shown that zinc-phosphate cement attains 2/3 of its final strength during the first hour and its maximum strength in approximately 24 hours, after which it remains stable.2022 This behavior may explain why the groups tested at 15 minutes had lower retention than those tested at 1 and 24 hours. Interestingly, it has previously been found that posts cemented with zinc-phosphate cement and tested for retention after 90 minutes have lower retentive values than those tested after a week or a month,23 which is suggestive of an ongoing strengthening of the cement beyond 24 hours. The fact that the increases in retention of the unprepared groups with time were not statistically significantwhile for the prepared groups they were

Results
Retention generally increased with time following cementation for both the unprepared (1, 3, and 5) and prepared (2, 4, and 6) groups (Table 1). Group 2 specimens, which had their cores prepared at 15 minutes, had the lowest retention, while those in group 5, which represented unprepared cores tested after 24 hours, had the highest retention. Two-way ANOVA revealed a statistically significant difference in mean post retention between [AU: Correct?] unprepared and prepared groups (P < .0001), and there were also significant differences among the means of the three time points investigated ( P < .0001). However, ANOVA showed no interaction between the preparation and time factors (P = .193). This apparent disparity may have been due to the high standard deviations recorded, so that the P value could

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raises the question of the effect of mechanical disturbance on the properties of setting zinc-phosphate cement. The lowest dislodgment force was observed in the group that was prepared and tested at 15 minutes and was 43% lower than the time-matched unprepared group. At 1 hour, there was a 26% decrease in retention for the prepared group compared to its unprepared equivalent. In a previous study, a similar decrease in post retention after core preparation 1 hour after cementation was reported, compared to controls.18 In the present study, the effect of preparation was least noticeable in the group tested at 24 hours. This could have been due to the greater maturation of the cement at 24 hours,20,21 and even beyond, as previously indicated.23 It has been reported that the use of ultrasonic scalers on cemented posts breaks the cement film between the wall of the canal and the post, resulting in reduced post retention and easier post retrieval.10,11,24 Several authors therefore recommended that no adjustment by high-speed handpiece of the core be made shortly after cementation of the post and core.1517 The effect of defined applications of what may be regarded as mechanical vibration on cemented posts and cores was, for the present purposes, gauged by their capacity to resist withdrawal in an axial direction. The mechanism of retention under these conditions depends upon the shear strength of the luting agent as well as the compressive strength of cement, which engages irregularities in both the root and post surfaces.25,26 However, it is clear that retention is not the sole criterion of a successful post, and resistance to nonaxial stresses may be even more important. For the present purposes, and to control variables, nonaxial stresses were purposely minimized by means of a specially designed self-aligning connection to the specimens. Nevertheless, it is recognized that the absolute elimination of nonaxial force vectors is probably unlikely. Clinical research shows that, of the various modes of failure of teeth restored with a post, post loosening and dislodgment are the most frequently occurring types.1,2730 Stability and resistance to functional forces are important factors in the long-term success of a restored endodontically treated tooth,31,32 and any detrimental influence on the effectiveness of such stability would be considered a compromise to clinical longevity. One such negative influence may be the possible vibration induced by preparation of the core soon after cementation of the post and core, which the results of this study appear to confirm.

1. Retentive capacities of posts increased as a function of time for all prepared groups. 2. Preparation of cemented cast posts and cores using a diamond instrument in a high-speed handpiece had a significant negative effect on retention when carried out 15 minutes and 1 hour after cementation. 3. Preparation performed 24 hours after cementation had no significant effect on post retention. On the basis of these findings, it can be recommended that, at the clinical level, sufficient time be allowed for fabricating direct post-and-core patterns so that the need for core adjustment after cementation is minimized. Should castings need to be adjusted, it is recommended that no tooth preparation be performed immediately after cementation of the posts with zincphosphate cement. Instead, such adjustments should, as much as possible, be made prior to cementation.

Acknowledgments
This research was partly funded by King Abdulaziz City for Science and Technology and registered with the College of Dentistry Research Center under No. NF-1628. Special thanks are due to Dr Nazeer Khan for his guidance in the statistical treatments of the work.

References
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Conclusions
Under the conditions of this study, the following conclusions can be drawn:

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11. Johnson WT, Leary JM, Boyer DB. Effect of ultrasonic vibration on post removal in extracted human premolar teeth. J Endod 1996;22:487488. 12. Yoshida T, Gomyo S, Itoh T, Shibata T, Sekine I. An experimental study of the removal of cemented double-retained cast cores by ultrasonic vibration. J Endod 1997;23:239241. 13. Peyton FA, Henry EE. The effect of high-speed burs, diamond instrumentations and air abrasive in cutting tooth tissue. J Am Dent Assoc 1954;49:426435. 14. Morrison AH, Grinnell HW. The theoretical and functional [AU: Words missing?] of higher speed rotary instrumentation. J Prosthet Dent 1958;8:297314. 15. Dykema RW, Goodacre CJ, Phillips RW. Johnstons Modern Practice in Fixed Prosthodontics, ed 4. Philadelphia: Saunders, 1986:364378. 16. Abou-Rass M, Donovan TE. The restoration of endodontically treated teeth. J Calif Dent Assoc 1993;21:6167. 17. Baum L, Phillips R, Lund M. Textbook of Operative Dentistry, ed 3. Philadelphia: Saunders, 1995:59361. [AU: Please list correct page numbers.] 18. Lund PS, Wilcox LR. The effect of tooth preparation on retention and microleakage of cemented cast posts. J Prosthodont 1994;3: 29. 19. American National Standards Institute/American Dental Association. Specification No. 96 (ISO 9917) for Dental WaterBased Cements. Chicago: ANSI/ADA, 1994. 20. ilo G. Luting cements: A review and comparison. Int Dent J 1991;41:8188. 21. Phillips RW. Skinners Science of Dental Materials, ed 9. Philadelphia: Saunders, 1991:478503.

22. Craig RG. Restorative Dental Materials, ed 10. St Louis: MosbyYear Book, 1997:172208. 23. Hanson EC, Caputo AA. Cementing mediums and retentive characteristics of dowels. J Prosthet Dent 1974;32:551557. 24. Noguchi S, Nakamura Y, Mukai S, Hanamura N. The removal of cemented dowels by ultrasonic [AU: Word(s) missing? (Or ultrasound?)], Part I. J Jpn Prosthodont Soc 1988;32:755762. 25. Standlee JP, Caputo AA, Hanson EC. Retention of endodontic dowels: Effects of cement, dowel length, diameter and design. J Prosthet Dent 1978;39:401405. 26. Jacobi R, Shillingburg HT. Pins, dowels, and other retentive devices in posterior teeth. Dent Clin North Am 1993;37:367390. 27. Turner CH. The utilization of roots to carry post-retained crowns. J Oral Rehabil 1982;9:193202. 28. Lewis R, Smith BG. A clinical survey of failed post retained crowns. Br Dent J 1988;165:9597. 29. Mentink AGB, Meeuwissen R, Kyser AF, Mulder J. Survival rate and failure characteristics of the all-metal post and core restoration. J Oral Rehabil 1993;20:455461. 30. Torbjrner A, Karlsson S, dman PA. Survival rate and failure characteristics for two post designs. J Prosthet Dent 1995;73:439444. 31. Libman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodont 1995;8:155161. 32. Cohen B, Pagnillo M, Newman I, Musikant B, Deutsch A. Effects of three bonding systems on the torsional resistance of titanium reinforced composite cores supported by two post designs. J Prosthet Dent 1999;81:678683.

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